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General NPI Number Information
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NPI Number | 1912381658
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Entity Type | Organization
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Legal Business Name | JASON M. LANE DDS, LLC
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Dates
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Enumeration Date | 07/13/2015
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Last Update Date | 07/13/2015
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Provider Practice Location Address
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Address Line | 23375 W BELUGA AVE SUITE B
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City | WILLOW
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State | AK
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Zip | 99688
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Country | US
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Telephone | 907-631-3521
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Fax |
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Provider Business Mailing Address
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Address Line | 2000 S HYGRADE CIR
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City | WASILLA
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State | AK
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Zip | 99654-8561
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Country | US
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Telephone | 907-631-3521
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | JASON LANE
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Credential | DDS
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Telephone | 520-227-6521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 100868
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License Number State | AK
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