=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356993885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON RAE LANIER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 02/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 BARTON CREEK CT
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-8027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-281-3570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 OCEANIA NECK CT
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-7250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-302-9037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9432
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------