Healthcare Provider Details

I. General information

NPI: 1174833396
Provider Name (Legal Business Name): MARTHA L LEWIS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MAIN STREET E
UTICA MS
39175
US

IV. Provider business mailing address

315 MORRISON DRIVE
CLINTON MS
39058
US

V. Phone/Fax

Practice location:
  • Phone: 601-885-8537
  • Fax: 601-885-8539
Mailing address:
  • Phone: 601-925-5163
  • Fax: 601-925-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2559-90
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: