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General NPI Number Information
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NPI Number | 1326440041
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Entity Type | Individual
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Provider Name | LANE MEDINA D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 09/24/2014
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Last Update Date | 09/24/2014
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Provider Practice Location Address
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Address Line | 1061 S STATE ROUTE 260
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City | COTTONWOOD
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State | AZ
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Zip | 86326-4624
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Country | US
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Telephone | 928-472-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 1061 S STATE ROUTE 260
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City | COTTONWOOD
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State | AZ
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Zip | 86326-4624
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D009043
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License Number State | AZ
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