MEDICARE: LANE AND ASSOCIATES XXXIX DDS PA

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
2	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538776455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANE AND ASSOCIATES XXXIX DDS PA

Provider Business Mailing Address
First Line	:	161 KODIAK LN
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-5399
Country	:	US
Telephone Number	:	336-789-1025
Fax Number	:	336-789-1158

Provider Business Practice Location Address
First Line	:	161 KODIAK LN
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-5399
Country	:	US
Telephone Number	:	336-789-1025
Fax Number	:	336-789-1158

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	ALICIA DUFFY
Credential	:
Telephone Number	:	919-295-2757

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	10/06/2022

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