Provider Demographics
NPI:1104032275
Name:TIMOTHY C. LANG, DDS, MD, PA
Entity Type:Organization
Organization Name:TIMOTHY C. LANG, DDS, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CORRIGAN
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:321-777-2166
Mailing Address - Street 1:2030 S PATRICK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4400
Mailing Address - Country:US
Mailing Address - Phone:321-777-2166
Mailing Address - Fax:321-777-2191
Practice Address - Street 1:2030 S PATRICK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4400
Practice Address - Country:US
Practice Address - Phone:321-777-2166
Practice Address - Fax:321-777-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00685011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
791334OtherUNITED CONCORDIA ID
FL253999300Medicaid
FL995474OtherCOMPBENEFITS FACILITY NUM
FL27225OtherBLUE CROSS BLUE SHIELD
FLF73185Medicare UPIN
FLGL607AMedicare PIN