Provider Demographics
NPI:1619436391
Name:LEWIS, TIARA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIARA
Middle Name:R
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 1:245 RIVER BASIN DR APT 301
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5149
Mailing Address - Country:US
Mailing Address - Phone:229-415-3170
Mailing Address - Fax:
Practice Address - Street 1:245 RIVER BASIN DR APT 301
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5149
Practice Address - Country:US
Practice Address - Phone:229-415-3170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24920122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program