Provider Demographics
NPI:1417401175
Name:LEWIS, ROTH RUBE HARRISON
Entity Type:Individual
Prefix:
First Name:ROTH RUBE
Middle Name:HARRISON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3327 RAINVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-5804
Mailing Address - Country:US
Mailing Address - Phone:302-332-5375
Mailing Address - Fax:
Practice Address - Street 1:3327 RAINVIEW CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-5804
Practice Address - Country:US
Practice Address - Phone:302-332-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist