Healthcare Provider Details

I. General information

NPI: 1114140597
Provider Name (Legal Business Name): DAVID WILLIAM LANGE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9157 MONTGOMERY RD
CINCINNATI OH
45242-7731
US

IV. Provider business mailing address

9157 MONTGOMERY RD
CINCINNATI OH
45242-7731
US

V. Phone/Fax

Practice location:
  • Phone: 513-791-0777
  • Fax: 513-791-7817
Mailing address:
  • Phone: 513-791-0777
  • Fax: 513-791-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.012903
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: