Provider Demographics
NPI:1457445439
Name:MINTLE, LANCE (OD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:MINTLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9606 271ST ST NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-8096
Mailing Address - Country:US
Mailing Address - Phone:360-939-0604
Mailing Address - Fax:
Practice Address - Street 1:9606 271ST ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-8096
Practice Address - Country:US
Practice Address - Phone:360-939-0604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3257OtherSTATE LICENSE NUMBER
WA2034742Medicaid
WA2034742Medicaid
WA3257OtherSTATE LICENSE NUMBER
WAG8877177Medicare PIN
WAU60308Medicare UPIN