Provider Demographics
NPI:1336671304
Name:LEWIS, KASSIDY (DMD)
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6595
Mailing Address - Country:US
Mailing Address - Phone:770-324-2821
Mailing Address - Fax:
Practice Address - Street 1:10 DEER CROSSING TRCE
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-1496
Practice Address - Country:US
Practice Address - Phone:706-445-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0155881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program