Provider Demographics
NPI:1437216124
Name:LEWIS, CHARLES J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
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 1:4366 LOG CABIN DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-5604
Mailing Address - Country:US
Mailing Address - Phone:478-471-6060
Mailing Address - Fax:478-476-8009
Practice Address - Street 1:4366 LOG CABIN DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-5604
Practice Address - Country:US
Practice Address - Phone:478-471-6060
Practice Address - Fax:478-476-8009
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice