Provider Demographics
NPI:1295093268
Name:DEAN, LANCE (PTA)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:DEAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96114-0404
Mailing Address - Country:US
Mailing Address - Phone:530-310-9135
Mailing Address - Fax:
Practice Address - Street 1:461-935 JANESVILLE GRADE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:CA
Practice Address - Zip Code:96114
Practice Address - Country:US
Practice Address - Phone:530-253-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6521172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker