Provider Demographics
NPI:1467466698
Name:LEWIS, MARK ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
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 1:6443 W 10TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-6501
Mailing Address - Country:US
Mailing Address - Phone:317-247-9512
Mailing Address - Fax:317-484-6393
Practice Address - Street 1:6443 W 10TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-6501
Practice Address - Country:US
Practice Address - Phone:317-247-9512
Practice Address - Fax:317-484-6393
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008006A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice