Provider Demographics
NPI:1720530645
Name:LANGE, RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:LANGE
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 1:108 CLEARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-6261
Mailing Address - Country:US
Mailing Address - Phone:951-901-9597
Mailing Address - Fax:
Practice Address - Street 1:17897 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-0533
Practice Address - Country:US
Practice Address - Phone:949-251-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1004391223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice