Healthcare Provider Details

I. General information

NPI: 1467522474
Provider Name (Legal Business Name): EDWARD SIDNEY LANE II D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 MURRAY RD
MEMPHIS TN
38119-3879
US

IV. Provider business mailing address

5565 MURRAY RD
MEMPHIS TN
38119-3879
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-8152
  • Fax: 901-761-2574
Mailing address:
  • Phone: 901-767-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3825
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: