Provider Demographics
NPI:1164594032
Name:LANIER, IDA BEATRICE (DDS)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:BEATRICE
Last Name:LANIER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 PANOLA RD STE A
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2494
Mailing Address - Country:US
Mailing Address - Phone:770-593-3426
Mailing Address - Fax:770-593-3672
Practice Address - Street 1:3035 PANOLA RD STE A
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2494
Practice Address - Country:US
Practice Address - Phone:770-593-3426
Practice Address - Fax:770-593-3672
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00586154AMedicaid