Healthcare Provider Details

I. General information

NPI: 1730276080
Provider Name (Legal Business Name): JANEAN LEWIS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 3RD AVE N
PAYETTE ID
83661-2407
US

IV. Provider business mailing address

1717 COX RD
WEISER ID
83672-5811
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-9763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-1958
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: