Provider Demographics
NPI:1477866275
Name:JERRY L LANIER DDS INC
Entity Type:Organization
Organization Name:JERRY L LANIER DDS INC
Other - Org Name:KIDS DENTAL KARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-345-0337
Mailing Address - Street 1:1127 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2505
Mailing Address - Country:US
Mailing Address - Phone:323-345-0337
Mailing Address - Fax:
Practice Address - Street 1:1127 E GREEN ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2505
Practice Address - Country:US
Practice Address - Phone:323-345-0337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356489660Medicaid