Provider Demographics
NPI:1891200861
Name:LANGSTON ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:LANGSTON ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:508-759-4495
Mailing Address - Street 1:114 WATERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-8340
Mailing Address - Country:US
Mailing Address - Phone:508-759-4495
Mailing Address - Fax:508-759-0840
Practice Address - Street 1:114 WATERHOUSE RD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-8340
Practice Address - Country:US
Practice Address - Phone:508-759-4495
Practice Address - Fax:508-759-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty