MEDICARE: DR. CARLA RENEE 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		IL

General Provider Information

NPI Number	:	1740305515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLA RENEE LEWIS D.D.S.

Provider Business Mailing Address
First Line	:	3129 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2203
Country	:	US
Telephone Number	:	618-274-4040
Fax Number	:	618-274-0452

Provider Business Practice Location Address
First Line	:	3129 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2203
Country	:	US
Telephone Number	:	618-274-4040
Fax Number	:	618-274-0452

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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