Individual
DR. JONATHAN DANIEL LANE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
38717 38TH STREET, DENTAC CREDENTIALS OFFICE, FORT GORDON, GA 30905-5660
(706) 787-6927
(706) 787-2082
Mailing address
HQ, 618TH DENTAL COMPANY (AS), UNIT #15652, BLDG S-5403, APO, AP 96205-5652
(011) 822-2600
(315) 737-2600
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DS039289
PA
1223P0300X
Periodontics
Primary
DS039289
PA
Other
Enumeration date
08/08/2012
Last updated
07/26/2016
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