Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | PENDING-1 | NY |
NPI | 1003800970 |
---|---|
Provider Name | Dr. Brendan Matthew Lane |
First Address | Dover, DE 19901-7811 |
Second Address | Dover Afb, DE 19902-5300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 08/07/2007 |