Healthcare Provider Details

I. General information

NPI: 1689761025
Provider Name (Legal Business Name): JEFFREY SCOTT LEWIS M.D., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EAST BUFFALO STREET SUITE 304
ITHACA NY
14850
US

IV. Provider business mailing address

200 EAST BUFFALO STREET #304
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-277-7007
  • Fax: 607-277-5434
Mailing address:
  • Phone: 607-277-7007
  • Fax: 607-277-5434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number197617-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number544761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: