Healthcare Provider Details

I. General information

NPI: 1588838403
Provider Name (Legal Business Name): LEWIS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N KELLY AVE
EDMOND OK
73003-3233
US

IV. Provider business mailing address

2900 N KELLY AVE
EDMOND OK
73003-3233
US

V. Phone/Fax

Practice location:
  • Phone: 405-330-5095
  • Fax: 405-330-9945
Mailing address:
  • Phone: 405-330-5095
  • Fax: 405-330-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number157
License Number StateOK

VIII. Authorized Official

Name: DR. SHANNON M. LEWIS
Title or Position: DOCTOR
Credential: DDS, MS
Phone: 405-330-5095