Basic Information
| Provider Information | |||||||||
| NPI: | 1306832431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | CORRIGAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, MD, PHD | ||||||||
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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: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | ME0068501 | FL | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | DN14085 | FL | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 791334 | 01 | UNITED CONCORDIA PROVIDER | OTHER |