Provider Demographics
NPI:1457772816
Name:ANDERSON LANE DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:ANDERSON LANE DENTAL CENTER PLLC
Other - Org Name:ANDERSON LANE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:PEVOW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-459-4347
Mailing Address - Street 1:1802 W ANDERSON LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1338
Mailing Address - Country:US
Mailing Address - Phone:512-459-4347
Mailing Address - Fax:512-459-4348
Practice Address - Street 1:1802 W ANDERSON LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1338
Practice Address - Country:US
Practice Address - Phone:512-459-4347
Practice Address - Fax:512-459-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty