Healthcare Provider Details

I. General information

NPI: 1003895368
Provider Name (Legal Business Name): BRETT RAYMOND LANGSTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 N WILLIAMSBURG DR
DECATUR GA
30033-3500
US

IV. Provider business mailing address

1991 N WILLIAMSBURG DR
DECATUR GA
30033-3500
US

V. Phone/Fax

Practice location:
  • Phone: 706-877-6526
  • Fax:
Mailing address:
  • Phone: 706-877-6526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN01311
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN013111
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: