Healthcare Provider Details

I. General information

NPI: 1831398502
Provider Name (Legal Business Name): JASON WILLIAM LANG D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1982 HOLLAND AVE
PORT HURON MI
48060-1520
US

IV. Provider business mailing address

11300 E 13 MILE RD
WARREN MI
48093-2500
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-7300
  • Fax: 810-985-7803
Mailing address:
  • Phone: 586-573-6308
  • Fax: 586-573-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901018376
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: