Healthcare Provider Details

I. General information

NPI: 1346343407
Provider Name (Legal Business Name): DAVID FORREST LANE DDS MS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 CRANE RIDGE DRIVE SUITE D
JACKSON MS
39216
US

IV. Provider business mailing address

1855 CRANE RIDGE DRIVE SUITE D
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-7073
  • Fax:
Mailing address:
  • Phone: 601-981-7073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number169475
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberOR01078
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: