Provider Demographics
NPI:1386861078
Name:LANE, KERRY JURGENS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:JURGENS
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 1:325 MEETING HOUSE LN
Mailing Address - Street 2:SUITE H
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5087
Mailing Address - Country:US
Mailing Address - Phone:631-283-1543
Mailing Address - Fax:631-287-4598
Practice Address - Street 1:325 MEETING HOUSE LANE
Practice Address - Street 2:SUITE H
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11946
Practice Address - Country:US
Practice Address - Phone:631-283-1543
Practice Address - Fax:631-287-4598
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042010-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY042010-1OtherDENTAL LICENSE
NYBL1776989OtherDEA