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General NPI Number Information
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NPI Number | 1487106282
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Entity Type | Organization
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Legal Business Name | LEWIS FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 10/27/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 2401 E BROADWAY
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City | LOGANSPORT
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State | IN
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Zip | 46947-2056
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Country | US
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Telephone | 574-722-3107
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Fax | 574-722-1080
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Provider Business Mailing Address
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Address Line | 2401 E BROADWAY
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City | LOGANSPORT
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State | IN
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Zip | 46947-2056
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Country | US
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Telephone | 574-722-3107
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Fax | 574-722-1080
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. JAY LEWIS
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Credential | DDS
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Telephone | 574-722-3107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 12008646
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License Number State | IN
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