Healthcare Provider Details

I. General information

NPI: 1265464366
Provider Name (Legal Business Name): BENNIE W. LANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LANE #A 214
DALLAS TX
75230-0000
US

IV. Provider business mailing address

7777 FOREST LANE #A 214
DALLAS TX
75230-0000
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-7860
  • Fax: 972-566-6673
Mailing address:
  • Phone: 972-566-7860
  • Fax: 972-566-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD4190
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: