Healthcare Provider Details

I. General information

NPI: 1144635467
Provider Name (Legal Business Name): JAMES BROOKE LEWIS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 PIERCE RD
CLIFTON PARK NY
12065-1302
US

IV. Provider business mailing address

8 ERINN CT
WILTON NY
12831-2520
US

V. Phone/Fax

Practice location:
  • Phone: 518-373-1181
  • Fax: 215-707-0083
Mailing address:
  • Phone: 610-420-4948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number059506
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: