Provider Demographics
NPI:1346343407
Name:LANE, DAVID FORREST (DDS MS PA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:FORREST
Last Name:LANE
Suffix:
Gender:M
Credentials:DDS MS PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1855 CRANE RIDGE DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-981-7073
Mailing Address - Fax:
Practice Address - Street 1:1855 CRANE RIDGE DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-981-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1694751223X0400X
MSOR010781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics