Provider Demographics
NPI:1164779294
Name:LANE, JONATHAN DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:LANE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HQ, 618TH DENTAL COMPANY (AS)
Mailing Address - Street 2:UNIT #15652, BLDG S-5403
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5652
Mailing Address - Country:US
Mailing Address - Phone:011-822-2600
Mailing Address - Fax:315-737-2600
Practice Address - Street 1:38717 38TH STREET
Practice Address - Street 2:DENTAC CREDENTIALS OFFICE
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5660
Practice Address - Country:US
Practice Address - Phone:706-787-6927
Practice Address - Fax:706-787-2082
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039289122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist