Provider Demographics
NPI:1437859501
Name:WITT, LANE
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:WITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON AFB
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-1933
Mailing Address - Fax:
Practice Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON AFB
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist