Provider Demographics
NPI:1568636611
Name:LANE, JEFFREY WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WALTER
Last Name:LANE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2343
Mailing Address - Country:US
Mailing Address - Phone:856-429-1333
Mailing Address - Fax:
Practice Address - Street 1:208 N HADDON AVE
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2343
Practice Address - Country:US
Practice Address - Phone:856-429-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-19
Last Update Date:2008-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023629001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice