Provider Demographics
NPI:1154364396
Name:LEWIS, PHOEBY K (DMD)
Entity type:Individual
Prefix:
First Name:PHOEBY
Middle Name:K
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:716-562-4447
Mailing Address - Fax:
Practice Address - Street 1:1536 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3130
Practice Address - Country:US
Practice Address - Phone:478-781-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0110941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA559750905AMedicaid
GA81635OtherUNITED CONC.
GA0007529OtherDORAL
GA100678OtherAVESIS