Healthcare Provider Details

I. General information

NPI: 1124688841
Provider Name (Legal Business Name): LEWIS JOHN DILLARD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5283 BELLS FERRY RD
ACWORTH GA
30102-2500
US

IV. Provider business mailing address

5283 BELLS FERRY RD # RR
ACWORTH GA
30102-2500
US

V. Phone/Fax

Practice location:
  • Phone: 770-516-7153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN123372
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042192
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN123372
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS042192
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: