Provider Demographics
NPI:1780848788
Name:LEWIS, WALTER GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:GLENN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:2526 SHALLOWFORD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3053
Mailing Address - Country:US
Mailing Address - Phone:770-924-7826
Mailing Address - Fax:770-924-2822
Practice Address - Street 1:2526 SHALLOWFORD RD
Practice Address - Street 2:SUITE A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3053
Practice Address - Country:US
Practice Address - Phone:770-924-7826
Practice Address - Fax:770-924-2822
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GADN0097531223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics