Provider Demographics
NPI:1427033661
Name:LEWIS, JEREMY ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALLEN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2177
Mailing Address - Country:US
Mailing Address - Phone:850-526-4220
Mailing Address - Fax:
Practice Address - Street 1:4307 3RD AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2177
Practice Address - Country:US
Practice Address - Phone:850-526-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076091900Medicaid
FLDC17076OtherDENTAL LICENSE