Healthcare Provider Details

I. General information

NPI: 1932391455
Provider Name (Legal Business Name): SUE ELIZABETH LANGHAM D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 PEABODY AVE
MEMPHIS TN
38104-4506
US

IV. Provider business mailing address

1210 PEABODY AVE
MEMPHIS TN
38104-4506
US

V. Phone/Fax

Practice location:
  • Phone: 901-272-0003
  • Fax:
Mailing address:
  • Phone: 901-272-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8405
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: