Provider Demographics
NPI:1275706871
Name:BRAVMAN LANGSTON AND ASSOCIATES ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:BRAVMAN LANGSTON AND ASSOCIATES ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRAVMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:508-771-6665
Mailing Address - Street 1:68 CAMP STREET
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02061
Mailing Address - Country:US
Mailing Address - Phone:508-771-6665
Mailing Address - Fax:
Practice Address - Street 1:68 CAMP STREET
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02061
Practice Address - Country:US
Practice Address - Phone:508-771-6665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX04486OtherBCBS IND. #
MAX11180OtherBCBS
MADX9762OtherMEDICARE PTAN GROUP
MADX9762OtherMEDICARE PTAN GROUP