Provider Demographics
NPI:1396890984
Name:LEWIS, CYNTHIA DAWN (EFDA)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:DAWN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18036 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5035
Mailing Address - Country:US
Mailing Address - Phone:503-760-2495
Mailing Address - Fax:
Practice Address - Street 1:360 NW BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3852
Practice Address - Country:US
Practice Address - Phone:503-667-7480
Practice Address - Fax:503-667-7498
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9394126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant