Provider Demographics
NPI:1538776455
Name:LANE AND ASSOCIATES XXXIX DDS PA
Entity type:Organization
Organization Name:LANE AND ASSOCIATES XXXIX DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-295-2757
Mailing Address - Street 1:161 KODIAK LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5399
Mailing Address - Country:US
Mailing Address - Phone:336-789-1025
Mailing Address - Fax:336-789-1158
Practice Address - Street 1:161 KODIAK LN
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5399
Practice Address - Country:US
Practice Address - Phone:336-789-1025
Practice Address - Fax:336-789-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5070979Medicaid