Provider Demographics
NPI:1174833396
Name:LEWIS, MARTHA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MORRISON DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39058
Mailing Address - Country:US
Mailing Address - Phone:601-925-5163
Mailing Address - Fax:601-925-5184
Practice Address - Street 1:105 MAIN STREET E
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MS
Practice Address - Zip Code:39175
Practice Address - Country:US
Practice Address - Phone:601-885-8537
Practice Address - Fax:601-885-8539
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2559-90122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist