Basic Information
| Provider Information | |||||||||
| NPI: | 1104032275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIMOTHY C. LANG, DDS, MD, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217772166 | ||||||||
| FaxNumber: | 3217772191 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217772166 | ||||||||
| FaxNumber: | 3217772191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | LANG | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | CORRIGAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3217772166 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS, MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | ME0068501 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 791334 | 01 | UNITED CONCORDIA ID | OTHER | 253999300 | 05 | FL | MEDICAID | 995474 | 01 | FL | COMPBENEFITS FACILITY NUM | OTHER | 27225 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |