Provider Demographics
NPI:1164694824
Name:LAN D. DUCKETT DDS PC
Entity Type:Organization
Organization Name:LAN D. DUCKETT DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:7032-410-5775
Mailing Address - Street 1:101 W BROAD ST
Mailing Address - Street 2:STE 510
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4229
Mailing Address - Country:US
Mailing Address - Phone:703-241-5775
Mailing Address - Fax:703-241-2749
Practice Address - Street 1:101 W BROAD ST
Practice Address - Street 2:STE 510
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4229
Practice Address - Country:US
Practice Address - Phone:703-241-5775
Practice Address - Fax:703-241-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty