Provider Demographics
NPI:1447659925
Name:LEWIS, MATTHEW JAMES (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
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 1:3451 W KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8949
Mailing Address - Country:US
Mailing Address - Phone:918-307-0909
Mailing Address - Fax:918-307-1785
Practice Address - Street 1:3451 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8949
Practice Address - Country:US
Practice Address - Phone:918-307-0909
Practice Address - Fax:918-307-1785
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK66551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice