Provider Demographics
NPI:1740311406
Name:LANE, RICHARD CLARK (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CLARK
Last Name:LANE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2300
Mailing Address - Country:US
Mailing Address - Phone:707-762-6645
Mailing Address - Fax:707-762-2447
Practice Address - Street 1:131 LYNCH CREEK WAY
Practice Address - Street 2:SUITE C
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2300
Practice Address - Country:US
Practice Address - Phone:707-762-6645
Practice Address - Fax:707-762-2447
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice