Provider Demographics
NPI:1366560401
Name:GARY A. LEWIS, D.M.D., P.A.
Entity type:Organization
Organization Name:GARY A. LEWIS, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-7072
Mailing Address - Street 1:107 DRENNON DR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0011
Mailing Address - Country:US
Mailing Address - Phone:912-427-7072
Mailing Address - Fax:912-427-9350
Practice Address - Street 1:107 DRENNON DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0011
Practice Address - Country:US
Practice Address - Phone:912-427-7072
Practice Address - Fax:912-427-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00163732BMedicaid