Provider Demographics
NPI:1740305515
Name:LEWIS, CARLA RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:RENEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-2203
Mailing Address - Country:US
Mailing Address - Phone:618-274-4040
Mailing Address - Fax:618-274-0452
Practice Address - Street 1:3129 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-2203
Practice Address - Country:US
Practice Address - Phone:618-274-4040
Practice Address - Fax:618-274-0452
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice