Provider Demographics
NPI:1245311521
Name:LANE, KENNETH A (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:LANE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3864
Mailing Address - Country:US
Mailing Address - Phone:972-221-2564
Mailing Address - Fax:972-436-7964
Practice Address - Street 1:230 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3864
Practice Address - Country:US
Practice Address - Phone:972-221-2564
Practice Address - Fax:972-436-7964
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist