Basic Information
| Provider Information | |||||||||
| NPI: | 1164779294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | HQ, 618TH DENTAL COMPANY (AS) | ||||||||
| Address2: | UNIT #15652, BLDG S-5403 | ||||||||
| City: | APO | ||||||||
| State: | AP | ||||||||
| PostalCode: | 962055652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0118222600 | ||||||||
| FaxNumber: | 3157372600 | ||||||||
| Practice Location | |||||||||
| Address1: | 38717 38TH STREET | ||||||||
| Address2: | DENTAC CREDENTIALS OFFICE | ||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS039289 | PA | N | Dental Providers | Dentist | 1223P0300X | DS039289 | PA | Y | Dental Providers | Dentist | Periodontics |
No ID Information.