Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | MN11237 | MN |
NPI | 1003965195 |
---|---|
Provider Name | Linda Lewis |
First Address | Crosslake, MN 56442-2804 |
Second Address | Crosslake, MN 56442-2804 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2007 |
Last Update Date | 08/07/2007 |