Provider Demographics
NPI:1003800970
Name:LANE, BRENDAN MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:MATTHEW
Last Name:LANE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N DUPONT HWY
Mailing Address - Street 2:G-201
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-7811
Mailing Address - Country:US
Mailing Address - Phone:716-523-1008
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052483122300000X
NYPENDING-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist