Provider Demographics
NPI:1013017201
Name:PERIODONTICS & IMPLANT DENTISTRY OF ST. PETERSBURG
Entity Type:Organization
Organization Name:PERIODONTICS & IMPLANT DENTISTRY OF ST. PETERSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:G
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:727-579-8487
Mailing Address - Street 1:8487 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3609
Mailing Address - Country:US
Mailing Address - Phone:727-579-8487
Mailing Address - Fax:727-578-8500
Practice Address - Street 1:8487 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-3609
Practice Address - Country:US
Practice Address - Phone:727-579-8487
Practice Address - Fax:727-578-8500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN91121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty