MEDICARE: DR. KENT STOLPE LEWIS DDS

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	140478-9922	UT

General Provider Information

NPI Number	:	1063687911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENT STOLPE LEWIS DDS

Provider Business Mailing Address
First Line	:	4970 SOUTH 900 EAST
Second Line	:	SUITE G
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5776
Country	:	US
Telephone Number	:	801-262-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	4970 S 900 E
Second Line	:	SUITE G
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5776
Country	:	US
Telephone Number	:	801-262-9444
Fax Number	:

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

Provider Enumeration Date	:	04/22/2008
Last Update Date	:	04/22/2008

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