Provider Demographics
NPI:1275819708
Name:LANE & ASSOCIATES XXI, DDS PA
Entity Type:Organization
Organization Name:LANE & ASSOCIATES XXI, DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CONTRACTS AND DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-863-9763
Mailing Address - Street 1:4106 WAKE FOREST RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6398
Mailing Address - Country:US
Mailing Address - Phone:919-277-0577
Mailing Address - Fax:
Practice Address - Street 1:4106 WAKE FOREST RD
Practice Address - Street 2:SUITE 203
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6398
Practice Address - Country:US
Practice Address - Phone:919-277-0577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC47851223G0001X, 1223P0300X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty