Provider Demographics
NPI:1881123305
Name:LEWIS, KENNETH BOYD JR (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BOYD
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 RAMSEY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-7658
Mailing Address - Country:US
Mailing Address - Phone:910-488-0518
Mailing Address - Fax:
Practice Address - Street 1:4140 RAMSEY ST STE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-7658
Practice Address - Country:US
Practice Address - Phone:910-488-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice