MEDICARE: MARINA LANGE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	50559	CA

General Provider Information

NPI Number	:	1740499771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA LANGE DDS

Provider Business Mailing Address
First Line	:	1611 S CATALINA AVE
Second Line	:	SW 200
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5255
Country	:	US
Telephone Number	:	310-316-0850
Fax Number	:	310-316-0840

Provider Business Practice Location Address
First Line	:	1611 S CATALINA AVE
Second Line	:	SW 200
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5255
Country	:	US
Telephone Number	:	310-316-0850
Fax Number	:	310-316-0840

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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