Provider Demographics
NPI:1891797692
Name:LEWIS, SHANNON M (DDS, MS, PC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DDS, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N. KELLY AVENUE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003
Mailing Address - Country:US
Mailing Address - Phone:405-330-5095
Mailing Address - Fax:405-330-9945
Practice Address - Street 1:2900 N KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3233
Practice Address - Country:US
Practice Address - Phone:405-330-5095
Practice Address - Fax:405-330-9945
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200050900AMedicaid