Provider Demographics
NPI:1366608366
Name:LEWIS, WANDA L (DDS)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 N HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212-2442
Mailing Address - Country:US
Mailing Address - Phone:214-637-4604
Mailing Address - Fax:214-630-9258
Practice Address - Street 1:3524 N HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-2442
Practice Address - Country:US
Practice Address - Phone:214-637-4604
Practice Address - Fax:214-630-9258
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009742001Medicaid