Provider Demographics
NPI:1528144227
Name:LEWIS, NATHAN L (DDS)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17179
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-7179
Mailing Address - Country:US
Mailing Address - Phone:949-567-3176
Mailing Address - Fax:949-567-3185
Practice Address - Street 1:525 E MOANA LN STE A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-4692
Practice Address - Country:US
Practice Address - Phone:775-823-5100
Practice Address - Fax:775-823-5101
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2216361Medicaid