Provider Demographics
NPI:1811041700
Name:LANE AND ASSOCIATES XII DDS PA
Entity Type:Organization
Organization Name:LANE AND ASSOCIATES XII DDS PA
Other - Org Name:LANE AND ASSOCIATES XII
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-295-2757
Mailing Address - Street 1:4106 WAKE FOREST RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6227
Mailing Address - Country:US
Mailing Address - Phone:919-876-2464
Mailing Address - Fax:919-876-1409
Practice Address - Street 1:4106 WAKE FOREST RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6397
Practice Address - Country:US
Practice Address - Phone:919-876-2464
Practice Address - Fax:919-876-1409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC47851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016YFOtherBCBS-NC HEALTHCHOICE
NC89016TJMedicaid
NC016YFOtherBCBS-NC HEALTHCHOICE