Healthcare Provider Details

I. General information

NPI: 1104032275
Provider Name (Legal Business Name): TIMOTHY C. LANG, DDS, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 S PATRICK DR SUITE 1
INDIAN HARBOUR BEACH FL
32937-4400
US

IV. Provider business mailing address

2030 S PATRICK DR SUITE 1
INDIAN HARBOUR BEACH FL
32937-4400
US

V. Phone/Fax

Practice location:
  • Phone: 321-777-2166
  • Fax: 321-777-2191
Mailing address:
  • Phone: 321-777-2166
  • Fax: 321-777-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberME0068501
License Number StateFL

VIII. Authorized Official

Name: DR. TIMOTHY CORRIGAN LANG
Title or Position: CEO
Credential: DDS, MD
Phone: 321-777-2166