Provider Demographics
NPI:1245941186
Name:LANGE, THERESA MARIE (RDH)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:LANGE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:OSMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:4016 SCHEEL DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-9711
Mailing Address - Country:US
Mailing Address - Phone:308-645-9458
Mailing Address - Fax:
Practice Address - Street 1:1226 L ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:NE
Practice Address - Zip Code:68818-2047
Practice Address - Country:US
Practice Address - Phone:402-694-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1979124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist