Healthcare Provider Details

I. General information

NPI: 1013017201
Provider Name (Legal Business Name): PERIODONTICS & IMPLANT DENTISTRY OF ST. PETERSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8487 4TH ST N
ST PETERSBURG FL
33702-3609
US

IV. Provider business mailing address

8487 4TH ST N
ST PETERSBURG FL
33702-3609
US

V. Phone/Fax

Practice location:
  • Phone: 727-579-8487
  • Fax: 727-578-8500
Mailing address:
  • Phone: 727-579-8487
  • Fax: 727-578-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN9112
License Number StateFL

VIII. Authorized Official

Name: DR. GREGORY G LANGSTON
Title or Position: PRESIDENT
Credential: DMD, MSD
Phone: 727-579-8487