=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013233121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEWIS DENTAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2010
-----------------------------------------------------
Last Update Date | 04/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 N WASHINGTON AVE
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38012-2555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-779-0889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1299 BRIDGETON PARK DR
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-8341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PEETE DUANE LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-828-6811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8692
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------