Provider Demographics
NPI:1679769012
Name:LEWIS, TIMOTHY DALLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DALLAS
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 1:10938 PLUM VIEW LN
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-9310
Mailing Address - Country:US
Mailing Address - Phone:909-844-2327
Mailing Address - Fax:
Practice Address - Street 1:10938 PLUM VIEW LN
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-9310
Practice Address - Country:US
Practice Address - Phone:909-844-2327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA563301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice