Provider Demographics
NPI:1184780603
Name:LEWIS, KEVIN L (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
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 1:3900 BRISTOL HWY # B-14
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1378
Mailing Address - Country:US
Mailing Address - Phone:423-282-1842
Mailing Address - Fax:
Practice Address - Street 1:3900 BRISTOL HWY # B-14
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1378
Practice Address - Country:US
Practice Address - Phone:423-282-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0074081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4004301OtherBLUE CROSS BLUE SHIELD
TN451884OtherUNITED CONCORDIA