Healthcare Provider Details

I. General information

NPI: 1649233990
Provider Name (Legal Business Name): JAMES WARD LANE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MAIN STREET
CORNELL WI
54732
US

IV. Provider business mailing address

PO BOX 521 208 MAIN STREET
CORNELL WI
54732
US

V. Phone/Fax

Practice location:
  • Phone: 715-239-3166
  • Fax: 715-239-0346
Mailing address:
  • Phone: 715-239-3166
  • Fax: 715-239-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5002082G
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: