Provider Demographics
NPI:1639287253
Name:LEWIS, RANDALL DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
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 1:103 W. CLINTON ST.
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:MI
Mailing Address - Zip Code:48473
Mailing Address - Country:US
Mailing Address - Phone:989-288-6165
Mailing Address - Fax:989-288-2030
Practice Address - Street 1:103 W. CLINTON ST.
Practice Address - Street 2:SUITE A
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48473
Practice Address - Country:US
Practice Address - Phone:989-288-6165
Practice Address - Fax:989-288-2030
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010150881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice