Healthcare Provider Details

I. General information

NPI: 1376995274
Provider Name (Legal Business Name): LANE AND ASSOCIATES XXX, DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10677 US 15 501 HWY STE 100
SOUTHERN PINES NC
28387-5154
US

IV. Provider business mailing address

10677 US 15 501 HWY STE 100
SOUTHERN PINES NC
28387-5154
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-5980
  • Fax: 910-295-3593
Mailing address:
  • Phone: 910-295-5980
  • Fax: 910-295-3593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALICIA M DUFFY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-295-2757