Basic Information
Provider Information
NPI: 1003800970
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LANE
FirstName: BRENDAN
MiddleName: MATTHEW
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1700 N DUPONT HWY
Address2: G-201
City: DOVER
State: DE
PostalCode: 199017811
CountryCode: US
TelephoneNumber: 7165231008
FaxNumber:  
Practice Location
Address1: 300 TUSKEGEE BLVD
Address2:  
City: DOVER AFB
State: DE
PostalCode: 199025300
CountryCode: US
TelephoneNumber: 3026772525
FaxNumber: 3026772526
Other Information
ProviderEnumerationDate: 09/07/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XPENDING-1NYY Dental ProvidersDentist 

No ID Information.


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