Provider Demographics
NPI:1669543419
Name:LANGENBRUNNER, JOHN G (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:LANGENBRUNNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6524
Mailing Address - Country:US
Mailing Address - Phone:423-928-5500
Mailing Address - Fax:
Practice Address - Street 1:712 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6524
Practice Address - Country:US
Practice Address - Phone:423-928-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225187Medicaid