=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396187746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICE LANE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2013
-----------------------------------------------------
Last Update Date | 04/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7212 REGIONAL ST
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-201-6011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 W WATERMAN DR
-----------------------------------------------------
City | MOUNTAIN HOUSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95391-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-135-9819
-----------------------------------------------------
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 | 62660
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------