Healthcare Provider Details

I. General information

NPI: 1033266549
Provider Name (Legal Business Name): TIMOTHY A. LEW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9415 N BEACH ST
FORT WORTH TX
76244-9059
US

IV. Provider business mailing address

9415 N BEACH ST
FORT WORTH TX
76244-9059
US

V. Phone/Fax

Practice location:
  • Phone: 817-741-2200
  • Fax: 817-741-2216
Mailing address:
  • Phone: 817-741-2200
  • Fax: 817-741-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0022906
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: