Provider Demographics
NPI:1467517607
Name:LANGE, MARK ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALBERT
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 1:3961 LAKE POINT DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4690
Mailing Address - Country:US
Mailing Address - Phone:231-733-7708
Mailing Address - Fax:
Practice Address - Street 1:2320 GLADE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1317
Practice Address - Country:US
Practice Address - Phone:231-733-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0125221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4054547Medicaid