Provider Demographics
NPI:1932275567
Name:FALLIN, LANCE EVERETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:EVERETT
Last Name:FALLIN
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 1:1338 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2743
Mailing Address - Country:US
Mailing Address - Phone:225-654-2212
Mailing Address - Fax:225-654-3170
Practice Address - Street 1:1338 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2743
Practice Address - Country:US
Practice Address - Phone:225-654-2212
Practice Address - Fax:225-654-3170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA49541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice