=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548795206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANE DENTAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2017
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 W ARMY TRAIL RD
-----------------------------------------------------
City | CAROL STREAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60188-9068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-830-8330
-----------------------------------------------------
Fax | 630-823-8180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 940 W ARMY TRAIL RD
-----------------------------------------------------
City | CAROL STREAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60188-9068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-830-8330
-----------------------------------------------------
Fax | 630-823-8180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE SPECIALIST
-----------------------------------------------------
Name | JENNIFER STOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-857-1966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019029593
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------