Provider Demographics
NPI:1386262947
Name:LEWIS, KELSEY NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:NICOLE
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 1:5764 STEVENS FOREST RD APT 909
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3766
Mailing Address - Country:US
Mailing Address - Phone:609-610-2235
Mailing Address - Fax:
Practice Address - Street 1:4510 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1506
Practice Address - Country:US
Practice Address - Phone:410-233-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD169901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice