Provider Demographics
NPI:1235291287
Name:PANE, LARY MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:LARY
Middle Name:MICHAEL
Last Name:PANE
Suffix:
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 1:4420 ST CHARLES ROAD
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104
Mailing Address - Country:US
Mailing Address - Phone:708-547-7160
Mailing Address - Fax:630-426-0211
Practice Address - Street 1:4420 ST CHARLES ROAD
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104
Practice Address - Country:US
Practice Address - Phone:708-547-7160
Practice Address - Fax:630-426-0211
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005522Medicaid