Healthcare Provider Details

I. General information

NPI: 1417575424
Provider Name (Legal Business Name): EASTON KIDS DENTIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/11/2020
Certification Date: 07/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 DUTCHMANS LN
EASTON MD
21601-4304
US

IV. Provider business mailing address

613 DUTCHMANS LN
EASTON MD
21601-4304
US

V. Phone/Fax

Practice location:
  • Phone: 410-822-7575
  • Fax: 410-763-8929
Mailing address:
  • Phone: 410-822-7575
  • Fax: 410-763-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ERICA MICHELE LEWIS-MEAD
Title or Position: OWNER/ DENTIST
Credential: DDS
Phone: 410-822-7575