1063857902 NPI number — KENTON LANE DOVER MD

Table of content: KENTON LANE DOVER MD (NPI 1063857902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063857902 NPI number — KENTON LANE DOVER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOVER
Provider First Name:
KENTON
Provider Middle Name:
LANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063857902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 208057 300 CEDAR STREET TAC - 441 SOUTH
Provider Second Line Business Mailing Address:
PULMONARY AND CRITICAL CARE SECTION
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06520-8057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-785-4162
Provider Business Mailing Address Fax Number:
203-785-3826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 YORK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06510-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-688-4242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2017-00171 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 64852 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 64852 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 2017-00171 , 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)





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