Healthcare Provider Details

I. General information

NPI: 1295664571
Provider Name (Legal Business Name): LANE BAZAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 MOOSA BLVD
EUNICE LA
70535
US

IV. Provider business mailing address

PO BOX 678
PRAIRIEVILLE LA
70769-0678
US

V. Phone/Fax

Practice location:
  • Phone: 337-308-1853
  • Fax:
Mailing address:
  • Phone: 337-308-1853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7778
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: