Provider Demographics
NPI:1982722336
Name:LEWIS, TED CHARLES (DMD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:CHARLES
Last Name:LEWIS
Suffix:
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 1:4780 CRANDALL LANESVILLE RD NE
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-7058
Mailing Address - Country:US
Mailing Address - Phone:573-380-6235
Mailing Address - Fax:
Practice Address - Street 1:4780 CRANDALL LANESVILLE RD NE
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-7058
Practice Address - Country:US
Practice Address - Phone:573-380-6235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012055A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice