Provider Demographics
NPI:1356427942
Name:LEWIS, CHRISTINA LATRICIA (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:LATRICIA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:24293 TELEGRAPH RD
Mailing Address - Street 2:STE 212
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-7903
Mailing Address - Country:US
Mailing Address - Phone:734-728-1621
Mailing Address - Fax:734-722-2331
Practice Address - Street 1:24293 TELEGRAPH RD
Practice Address - Street 2:SUITE 212
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-3011
Practice Address - Country:US
Practice Address - Phone:248-223-5639
Practice Address - Fax:248-223-5689
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010175971223G0001X
OK58351223G0001X
CA550181223G0001X
NV4949T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4093385Medicaid
MID800438OtherBLUE CROSS/BLUE SHIELD