Provider Demographics
NPI:1710155080
Name:DUTTON LEWIS FAMILY DENTAL
Entity Type:Organization
Organization Name:DUTTON LEWIS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS (PEDIATRICS)
Authorized Official - Phone:713-633-5717
Mailing Address - Street 1:4418 ALMEDA RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-4902
Mailing Address - Country:US
Mailing Address - Phone:713-633-5717
Mailing Address - Fax:
Practice Address - Street 1:4418 ALMEDA RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-4902
Practice Address - Country:US
Practice Address - Phone:713-633-5717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179821223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG60405-02OtherCHIPS
TX149758801Medicaid
TX01367667OtherUNITED CONCORDIA