Basic Information
| Provider Information | |||||||||
| NPI: | 1689904757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DDS,PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 321 SPOKANE ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993541952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 73265 CONFEDERATED WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978010160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 01/12/2010 | ||||||||
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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 | D9382 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 171037 | 05 | OR | MEDICAID |