Provider Demographics
NPI:1629181417
Name:LAGE, RICHARD CHARLES III (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:LAGE
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:CHARLES
Other - Last Name:LAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS PA
Mailing Address - Street 1:1321 SW 107TH AVE
Mailing Address - Street 2:SUITE 216A
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2523
Mailing Address - Country:US
Mailing Address - Phone:305-226-3231
Mailing Address - Fax:
Practice Address - Street 1:1321 SW 107TH AVE
Practice Address - Street 2:SUITE 216A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2523
Practice Address - Country:US
Practice Address - Phone:305-226-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11477122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist