Provider Demographics
NPI:1083248017
Name:LANE, SHERRY (RDH)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 BUTTE DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9142
Mailing Address - Country:US
Mailing Address - Phone:970-731-3393
Mailing Address - Fax:
Practice Address - Street 1:2035 EAGLE DR UNIT 110
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9013
Practice Address - Country:US
Practice Address - Phone:970-731-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2078124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist