Provider Demographics
NPI:1598882326
Name:LANE, THOMAS RANDAL (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RANDAL
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 1:1831 NE 45TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5117
Mailing Address - Country:US
Mailing Address - Phone:954-771-3331
Mailing Address - Fax:954-771-7795
Practice Address - Street 1:1831 NE 45TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-5117
Practice Address - Country:US
Practice Address - Phone:954-771-3331
Practice Address - Fax:954-771-7795
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00112991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice