Provider Demographics
NPI:1134288335
Name:LANE, FRED L JR (DDS)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:L
Last Name:LANE
Suffix:JR
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 1:527 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216
Mailing Address - Country:US
Mailing Address - Phone:718-783-0414
Mailing Address - Fax:718-783-1422
Practice Address - Street 1:527 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216
Practice Address - Country:US
Practice Address - Phone:718-783-0414
Practice Address - Fax:718-783-1422
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00243031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00295318Medicaid
NY00295318Medicaid