Healthcare Provider Details

I. General information

NPI: 1174530729
Provider Name (Legal Business Name): JOHN WEST LEWIS III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE.
MEMPHIS TN
38104
US

IV. Provider business mailing address

VAMC DENTAL CLINIC 1030 JEFFERSON AVE.
MEMPHIS TN
38104
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 901-523-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number7793
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: