=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831398502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON WILLIAM LANG D.D.S., M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2007
-----------------------------------------------------
Last Update Date | 07/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1982 HOLLAND AVE
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-985-7300
-----------------------------------------------------
Fax | 810-985-7803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11300 E 13 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-573-6308
-----------------------------------------------------
Fax | 586-573-6308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 2901018376
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------