=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174833396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA L LEWIS D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2010
-----------------------------------------------------
Last Update Date | 10/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 MAIN STREET E
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-885-8537
-----------------------------------------------------
Fax | 601-885-8539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 MORRISON DRIVE
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-925-5163
-----------------------------------------------------
Fax | 601-925-5184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2559-90
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------