Provider Demographics
NPI:1346263134
Name:LANE, JEFFREY A (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:LANE
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 1:10530 ROSEHAVEN ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2840
Mailing Address - Country:US
Mailing Address - Phone:703-385-5777
Mailing Address - Fax:703-591-5386
Practice Address - Street 1:10530 ROSEHAVEN ST
Practice Address - Street 2:SUITE 111
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2840
Practice Address - Country:US
Practice Address - Phone:703-385-5777
Practice Address - Fax:703-591-5386
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010065701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA469265Z26Medicare UPIN