Provider Demographics
NPI:1043434426
Name:DELDEBBIO, LEWIS MICHAEL
Entity type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:MICHAEL
Last Name:DELDEBBIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 SOUTH OAK AVE
Mailing Address - Street 2:BUILDING 1 SUITE 1
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361
Mailing Address - Country:US
Mailing Address - Phone:209-847-1320
Mailing Address - Fax:209-847-4256
Practice Address - Street 1:190 S OAK AVE
Practice Address - Street 2:BUILDING 1 SUITE 1
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3528
Practice Address - Country:US
Practice Address - Phone:209-847-1320
Practice Address - Fax:209-847-4256
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist