Healthcare Provider Details

I. General information

NPI: 1871536029
Provider Name (Legal Business Name): GARRY L. LEWIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 5TH ST
MOUNDSVILLE WV
26041-1907
US

IV. Provider business mailing address

807 5TH ST
MOUNDSVILLE WV
26041-1907
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-5651
  • Fax: 304-845-5707
Mailing address:
  • Phone: 304-845-5651
  • Fax: 304-845-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2368
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: