Healthcare Provider Details

I. General information

NPI: 1891797692
Provider Name (Legal Business Name): SHANNON M. LEWIS DDS, MS, PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 02/27/2014
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 AVENUE
EDMOND OK
73003
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:
Title or Position:
Credential:
Phone: