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General NPI Number Information
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NPI Number | 1679098008
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Entity Type | Individual
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Provider Name | JOSHUA LEWIS
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Gender | Male
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Dates
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Enumeration Date | 08/07/2017
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 675 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5596
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Country | US
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Telephone | 208-538-0104
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Fax | 208-538-0106
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Provider Business Mailing Address
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Address Line | 675 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5596
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Country | US
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Telephone | 208-538-0104
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2017028241
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D5167
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5167
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License Number State | ID
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