MEDICARE: CRESTED OAK DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10481	CO

General Provider Information

NPI Number	:	1538591763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTED OAK DENTISTRY

Provider Business Mailing Address
First Line	:	2532 PATTERSON RD
Second Line	:	SUITE 1
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-3604
Country	:	US
Telephone Number	:	970-241-4800
Fax Number	:	970-241-8266

Provider Business Practice Location Address
First Line	:	2532 PATTERSON RD
Second Line	:	SUITE 1
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-3604
Country	:	US
Telephone Number	:	970-241-4800
Fax Number	:	970-241-8266

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. STEPHEN M LEWIS
Credential	:	DDS
Telephone Number	:	970-241-4800

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	07/27/2015

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