=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164594032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IDA BEATRICE LANIER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 02/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3035 PANOLA RD STE A
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30038-2494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-593-3426
-----------------------------------------------------
Fax | 770-593-3672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3035 PANOLA RD STE A
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30038-2494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-593-3426
-----------------------------------------------------
Fax | 770-593-3672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11228
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------