Provider Demographics
NPI:1588054779
Name:LANE EDDLEMAN, DDS, LLC
Entity type:Organization
Organization Name:LANE EDDLEMAN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-322-2013
Mailing Address - Street 1:2511 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2987
Mailing Address - Country:US
Mailing Address - Phone:318-322-2013
Mailing Address - Fax:318-322-2048
Practice Address - Street 1:2511 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2987
Practice Address - Country:US
Practice Address - Phone:318-322-2013
Practice Address - Fax:318-322-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1860590Medicaid
LA1855626Medicaid