Provider Demographics
NPI:1407069891
Name:LANGE, RONALD MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:MARK
Last Name:LANGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 N WAUWATOSA AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2241
Mailing Address - Country:US
Mailing Address - Phone:414-258-4332
Mailing Address - Fax:
Practice Address - Street 1:8651 S MARKET PL
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-3523
Practice Address - Country:US
Practice Address - Phone:414-764-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist