Provider Demographics
NPI:1568470433
Name:LEWIS, JACK DENNIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DENNIS
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:J
Other - Middle Name:DENNIS
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1770 E LAMBERT RD
Mailing Address - Street 2:#220
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-8005
Mailing Address - Country:US
Mailing Address - Phone:714-990-8891
Mailing Address - Fax:714-990-1649
Practice Address - Street 1:1770 E LAMBERT RD
Practice Address - Street 2:#220
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-8005
Practice Address - Country:US
Practice Address - Phone:714-990-8891
Practice Address - Fax:714-990-1649
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist