Provider Demographics
NPI:1740499771
Name:LANGE, MARINA (DDS)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:AMBARTSUMYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1611 S CATALINA AVE
Mailing Address - Street 2:SW 200
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5255
Mailing Address - Country:US
Mailing Address - Phone:310-316-0850
Mailing Address - Fax:310-316-0840
Practice Address - Street 1:1611 S CATALINA AVE
Practice Address - Street 2:SW 200
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5255
Practice Address - Country:US
Practice Address - Phone:310-316-0850
Practice Address - Fax:310-316-0840
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA505591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice