Provider Demographics
NPI:1831285287
Name:LEW, PAUL ILSUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ILSUN
Last Name:LEW
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 1:6314 NORTH RUCKER ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4895
Mailing Address - Country:US
Mailing Address - Phone:317-253-8004
Mailing Address - Fax:317-253-3861
Practice Address - Street 1:6314 NORTH RUCKER ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4895
Practice Address - Country:US
Practice Address - Phone:317-253-8004
Practice Address - Fax:317-253-3861
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006255A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice