Provider Demographics
NPI:1306969514
Name:SAMPLE, LEW B (DMD, MS, PC)
Entity type:Individual
Prefix:DR
First Name:LEW
Middle Name:B
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:DMD, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 DANVILLE PARK DR SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1832
Mailing Address - Country:US
Mailing Address - Phone:256-355-5255
Mailing Address - Fax:
Practice Address - Street 1:2014 DANVILLE PARK DR SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1832
Practice Address - Country:US
Practice Address - Phone:256-355-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL46681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL982261OtherUNITED CONCORDIA
AL4668OtherLICENSE NUMBER
AL08038OtherBLUE CROSS PROVIDER
AL982261OtherUNITED CONCORDIA