Provider Demographics
NPI:1962420646
Name:LANE, WILLIAM BLAKE (DDS, MSD, PC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BLAKE
Last Name:LANE
Suffix:
Gender:M
Credentials:DDS, MSD, PC
Other - Prefix:DR
Other - First Name:W.
Other - Middle Name:BLAKE
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MSD, PC
Mailing Address - Street 1:6440 BRADLEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3082
Mailing Address - Country:US
Mailing Address - Phone:706-323-7217
Mailing Address - Fax:706-324-4982
Practice Address - Street 1:6440 BRADLEY PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3082
Practice Address - Country:US
Practice Address - Phone:706-323-7217
Practice Address - Fax:706-324-4982
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics