1720131972 NPI number — LANE & ASSOCIATES DDS XVII PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720131972 NPI number — LANE & ASSOCIATES DDS XVII PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANE & ASSOCIATES DDS XVII PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720131972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12450 CLEVELAND RD
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-295-2757
Provider Business Mailing Address Fax Number:
919-295-2757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12450 CLEVELAND RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529-8355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-772-9927
Provider Business Practice Location Address Fax Number:
919-772-0647
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUFFY
Authorized Official First Name:
ALICIA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
919-295-2757

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4785 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5902254 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017K1 . This is a "BCBS-NC HEALTHCHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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