Provider Demographics
NPI:1942535265
Name:LANTZ, DANICA MALEINE (OD)
Entity Type:Individual
Prefix:
First Name:DANICA
Middle Name:MALEINE
Last Name:LANTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DANICA
Other - Middle Name:MALEINE
Other - Last Name:TEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:339 CROSS ROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-2194
Mailing Address - Country:US
Mailing Address - Phone:859-441-9464
Mailing Address - Fax:859-442-2023
Practice Address - Street 1:2555 PHILLIPS FIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3933
Practice Address - Country:US
Practice Address - Phone:907-328-2980
Practice Address - Fax:907-456-2914
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004551152W00000X
KY1933DT152W00000X
OH5914152W00000X
IN18003619A152W00000X
AK171318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G50032OtherBCBSM
IN000000660241OtherANTHEM
MIN88010004Medicare PIN
INM100059297Medicare PIN