Healthcare Provider Details

I. General information

NPI: 1437190469
Provider Name (Legal Business Name): JOHN STEPHEN LANGE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 N UNION
SPARTA MI
49345
US

IV. Provider business mailing address

62 N UNION
SPARTA MI
49345
US

V. Phone/Fax

Practice location:
  • Phone: 616-887-7355
  • Fax: 616-887-2005
Mailing address:
  • Phone: 616-887-7355
  • Fax: 616-887-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901011913
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: