Provider Demographics
NPI:1104288455
Name:LANE, JONATHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LANE
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 1:8505 KANSAS RIVER DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-8092
Mailing Address - Country:US
Mailing Address - Phone:765-749-7264
Mailing Address - Fax:
Practice Address - Street 1:1901 W WILLIAM CANNON DR STE 137
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5327
Practice Address - Country:US
Practice Address - Phone:765-749-7264
Practice Address - Fax:512-441-1799
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328051223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program