Provider Demographics
NPI:1003351503
Name:JACOB S LEWIS, DMD, P.C.
Entity type:Organization
Organization Name:JACOB S LEWIS, DMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-206-9541
Mailing Address - Street 1:829 W WAVELAND AVE
Mailing Address - Street 2:3S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2233 GREENBAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:312-206-9541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty