Healthcare Provider Details

I. General information

NPI: 1649470832
Provider Name (Legal Business Name): ROBERT DELL LEWIS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9776 W STATE ST
STAR ID
83669-5766
US

IV. Provider business mailing address

9776 W STATE ST
STAR ID
83669-5766
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-4080
  • Fax: 208-898-4095
Mailing address:
  • Phone: 208-898-4080
  • Fax: 208-898-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4065
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: