Provider Demographics
NPI:1053419051
Name:LEWIS, KEVIN AUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:AUSTIN
Last Name:LEWIS
Suffix:
Gender:M
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:RR 5 BOX 579
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-9323
Mailing Address - Country:US
Mailing Address - Phone:304-745-5215
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV33981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice