Basic Information
| Provider Information | |||||||||
| NPI: | 1154364396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | PHOEBY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165624447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1536 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312063130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787814333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN011094 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 559750905A | 05 | GA | MEDICAID | 81635 | 01 | GA | UNITED CONC. | OTHER | 0007529 | 01 | GA | DORAL | OTHER | 100678 | 01 | GA | AVESIS | OTHER |