Provider Demographics
NPI:1578749198
Name:BRIAN LANE D.D.S. P.A. 2
Entity Type:Organization
Organization Name:BRIAN LANE D.D.S. P.A. 2
Other - Org Name:MAYFLOWER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-470-9900
Mailing Address - Street 1:582 HIGHWAY 365 STE 4
Mailing Address - Street 2:
Mailing Address - City:MAYFLOWER
Mailing Address - State:AR
Mailing Address - Zip Code:72106-9525
Mailing Address - Country:US
Mailing Address - Phone:501-470-9900
Mailing Address - Fax:
Practice Address - Street 1:582 HIGHWAY 365 STE 4
Practice Address - Street 2:
Practice Address - City:MAYFLOWER
Practice Address - State:AR
Practice Address - Zip Code:72106-9525
Practice Address - Country:US
Practice Address - Phone:501-470-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty