Provider Demographics
NPI:1447688924
Name:JERRY L LANIER, DDS, INC
Entity type:Organization
Organization Name:JERRY L LANIER, DDS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-461-9942
Mailing Address - Street 1:4905 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6101
Mailing Address - Country:US
Mailing Address - Phone:323-461-9942
Mailing Address - Fax:
Practice Address - Street 1:1200 SAVIERS RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030
Practice Address - Country:US
Practice Address - Phone:323-461-9942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356489660Medicaid