Provider Demographics
NPI:1649470832
Name:LEWIS, ROBERT DELL (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DELL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9776 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5766
Mailing Address - Country:US
Mailing Address - Phone:208-898-4080
Mailing Address - Fax:208-898-4095
Practice Address - Street 1:9776 W STATE ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5766
Practice Address - Country:US
Practice Address - Phone:208-898-4080
Practice Address - Fax:208-898-4095
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-40651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808628400Medicaid