Provider Demographics
NPI:1225384746
Name:LANGE FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:LANGE FAMILY DENTISTRY, LLC
Other - Org Name:EDWARDS LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-655-8090
Mailing Address - Street 1:1930 EDWARDS LAKE RD
Mailing Address - Street 2:SUITE 134
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3718
Mailing Address - Country:US
Mailing Address - Phone:205-655-8090
Mailing Address - Fax:
Practice Address - Street 1:1930 EDWARDS LAKE RD
Practice Address - Street 2:SUITE 134
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3718
Practice Address - Country:US
Practice Address - Phone:205-655-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL57601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL125232Medicaid