Provider Demographics
NPI:1891872263
Name:RUSSELL G. LEWIS DDS PC
Entity Type:Organization
Organization Name:RUSSELL G. LEWIS DDS PC
Other - Org Name:SANDY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-572-0942
Mailing Address - Street 1:1434 E 9400 S
Mailing Address - Street 2:#201
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1434 E 9400 S
Practice Address - Street 2:#201
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-2957
Practice Address - Country:US
Practice Address - Phone:801-572-0942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT294428-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty