Provider Demographics
NPI:1790780641
Name:LEWIS, JACK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WILLIAM
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 1:7506 COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-2006
Mailing Address - Country:US
Mailing Address - Phone:214-642-9460
Mailing Address - Fax:
Practice Address - Street 1:7506 COTTONWOOD CT
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-2006
Practice Address - Country:US
Practice Address - Phone:214-642-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX164371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009782601Medicaid
TX007649901Medicaid