MEDICARE: DR. CHARLES J LEWIS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6769	GA

General Provider Information

NPI Number	:	1437216124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES J LEWIS D.D.S.

Provider Business Mailing Address
First Line	:	4366 LOG CABIN DR
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-5604
Country	:	US
Telephone Number	:	478-471-6060
Fax Number	:	478-476-8009

Provider Business Practice Location Address
First Line	:	4366 LOG CABIN DR
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-5604
Country	:	US
Telephone Number	:	478-471-6060
Fax Number	:	478-476-8009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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