Provider Demographics
NPI:1780787119
Name:LEWIS, TIMOTHY EUGENE (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EUGENE
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 1:73 MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401
Mailing Address - Country:US
Mailing Address - Phone:573-221-1885
Mailing Address - Fax:
Practice Address - Street 1:501 CLINIC RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-221-3360
Practice Address - Fax:573-221-1472
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE015702122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004517Medicaid