Provider Demographics
NPI:1376057745
Name:PIEDMONT PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PIEDMONT PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-288-9445
Mailing Address - Street 1:2692 N RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1217
Mailing Address - Country:US
Mailing Address - Phone:320-260-0731
Mailing Address - Fax:
Practice Address - Street 1:2600 OAKCREST AVE STE A
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-1935
Practice Address - Country:US
Practice Address - Phone:336-288-9445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty