MEDICARE: DR. NICOLE MARIE LANE D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	28892	TX

General Provider Information

NPI Number	:	1023456282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE MARIE LANE D.D.S

Provider Business Mailing Address
First Line	:	8505 QUAIL WOOD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78250-6516
Country	:	US
Telephone Number	:	915-276-1288
Fax Number	:	210-656-7660

Provider Business Practice Location Address
First Line	:	12311 NACOGDOCHES RD
Second Line	:	SUITE 206
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-2138
Country	:	US
Telephone Number	:	210-656-7600
Fax Number	:	210-656-7660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	06/10/2013

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