Provider Demographics
NPI:1740735026
Name:LANE, MICHELLE (DH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-689-2525
Mailing Address - Fax:
Practice Address - Street 1:1015 COLUMBIA
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WA
Practice Address - Zip Code:98813
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIL6058623124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist