Provider Demographics
NPI:1619296605
Name:LANCASTER, BRETT JACK (DMD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:JACK
Last Name:LANCASTER
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 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:1361 E 16TH ST
Practice Address - Street 2:#2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2008
Practice Address - Country:US
Practice Address - Phone:208-677-5198
Practice Address - Fax:208-678-2245
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD-44121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program