Provider Demographics
NPI:1750028882
Name:LANE, MELANIE GISELA
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:GISELA
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19032 NW 23RD CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5338
Mailing Address - Country:US
Mailing Address - Phone:954-383-3038
Mailing Address - Fax:
Practice Address - Street 1:1937 N MILITARY TRL STE U
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-4764
Practice Address - Country:US
Practice Address - Phone:561-683-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC129191223G0001X
390200000X
FLDN27567122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program