Provider Demographics
NPI:1871505529
Name:LEWIS, KENNETH DWAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DWAYNE
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 1:1149 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7723
Mailing Address - Country:US
Mailing Address - Phone:432-362-7927
Mailing Address - Fax:432-362-7928
Practice Address - Street 1:1149 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7723
Practice Address - Country:US
Practice Address - Phone:432-362-7927
Practice Address - Fax:432-362-7928
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD15924OtherBCBS