Provider Demographics
NPI:1194845669
Name:LANGBERG, BLAINE J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:J
Last Name:LANGBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4027
Mailing Address - Country:US
Mailing Address - Phone:203-431-4466
Mailing Address - Fax:
Practice Address - Street 1:17 DANBURY RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4027
Practice Address - Country:US
Practice Address - Phone:203-431-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0090401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics