Provider Demographics
NPI:1790575769
Name:LANE-ILLESCAS, KAYLA (DDS)
Entity type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:
Last Name:LANE-ILLESCAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 KINGS POND RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6420
Mailing Address - Country:US
Mailing Address - Phone:336-587-1517
Mailing Address - Fax:
Practice Address - Street 1:12165 ELM ST
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1358
Practice Address - Country:US
Practice Address - Phone:410-651-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program