Healthcare Provider Details

I. General information

NPI: 1467466698
Provider Name (Legal Business Name): MARK ALAN LEWIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6443 W 10TH ST SUITE 204
INDIANAPOLIS IN
46214-6501
US

IV. Provider business mailing address

6443 W 10TH ST SUITE 204
INDIANAPOLIS IN
46214-6501
US

V. Phone/Fax

Practice location:
  • Phone: 317-247-9512
  • Fax: 317-484-6393
Mailing address:
  • Phone: 317-247-9512
  • Fax: 317-484-6393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008006A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: