Healthcare Provider Details

I. General information

NPI: 1265411524
Provider Name (Legal Business Name): LYNDSAY NICOLE LANGSTON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 NORTHSIDE PKWY NW BUILDING 5
ATLANTA GA
30327-3007
US

IV. Provider business mailing address

4200 NORTHSIDE PKWY NW BUILDING 5
ATLANTA GA
30327-3007
US

V. Phone/Fax

Practice location:
  • Phone: 404-352-3123
  • Fax:
Mailing address:
  • Phone: 404-352-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN013112
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: