Provider Demographics
NPI:1972517217
Name:VINES, THERON LANE JR (DDS)
Entity type:Individual
Prefix:DR
First Name:THERON
Middle Name:LANE
Last Name:VINES
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TERRY
Other - Middle Name:L
Other - Last Name:VINES
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:303 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4607
Mailing Address - Country:US
Mailing Address - Phone:909-793-8837
Mailing Address - Fax:909-335-0497
Practice Address - Street 1:303 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4607
Practice Address - Country:US
Practice Address - Phone:909-793-8837
Practice Address - Fax:909-335-0497
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist