Provider Demographics
NPI:1831711910
Name:BRIAN LANE D D S PA
Entity type:Organization
Organization Name:BRIAN LANE D D S PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-796-3903
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-0130
Mailing Address - Country:US
Mailing Address - Phone:501-796-3903
Mailing Address - Fax:
Practice Address - Street 1:17 EAGLE PARK DR
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-9050
Practice Address - Country:US
Practice Address - Phone:501-425-1583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty