Provider Demographics
NPI:1417080797
Name:LEWIS A. WILK, DMD, PC
Entity Type:Organization
Organization Name:LEWIS A. WILK, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-421-3512
Mailing Address - Street 1:1101 N FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360
Mailing Address - Country:US
Mailing Address - Phone:570-421-3512
Mailing Address - Fax:570-420-8134
Practice Address - Street 1:1101 N FIFTH ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360
Practice Address - Country:US
Practice Address - Phone:570-421-3512
Practice Address - Fax:570-420-8134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA018990-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA081994OtherBLUE SHIELD
PAT28280Medicare UPIN
PA081994Medicare PIN