MEDICARE: DR. MARK DAVID LEWIS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4775	NV
2	122300000X	Dentist	341592992	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	341592992	OTHER	UT	DENTIST LICENSE

General Provider Information

NPI Number	:	1205863941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DAVID LEWIS D.D.S.

Provider Business Mailing Address
First Line	:	7890 W ANN RD
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-5209
Country	:	US
Telephone Number	:	702-878-4397
Fax Number	:	702-658-8741

Provider Business Practice Location Address
First Line	:	7890 W ANN RD
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-5209
Country	:	US
Telephone Number	:	702-878-4397
Fax Number	:	702-658-8741

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	01/21/2015

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