Provider Demographics
NPI:1912381658
Name:JASON M. LANE DDS, LLC
Entity Type:Organization
Organization Name:JASON M. LANE DDS, LLC
Other - Org Name:WILLOW DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-227-6521
Mailing Address - Street 1:2000 S HYGRADE CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8561
Mailing Address - Country:US
Mailing Address - Phone:907-631-3521
Mailing Address - Fax:
Practice Address - Street 1:23375 W BELUGA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WILLOW
Practice Address - State:AK
Practice Address - Zip Code:99688
Practice Address - Country:US
Practice Address - Phone:907-631-3521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty