Provider Demographics
NPI:1386029833
Name:LEWIS, MICHAEL J (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUREAU OF MEDICINE AND SURGERY CREDENTIALS
Mailing Address - Street 2:554 KEILY ST.
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5000
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:BUREAU OF MEDICINE AND SURGERY CREDENTIALS
Practice Address - Street 2:554 KEILY ST.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5000
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT2604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist