Lange Family Dentistry, LLC

Contacts

Phone	+1 205-655-8090

Authorized person

Name	DR. ANDREW JASON LANGE
Role	OWNER
Phone	2056558090

Taxonomy

Taxonomy Code	1223G0001X - General Practice Dentistry
License Number	5760
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	125232
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2056558090
Plan sponsor’s address	1930 EDWARD LAKES ROAD, STE 134, BIRMINGHAM, AL, 35235

Signature of

Role	Plan administrator
Date	2024-06-05
Name of individual signing	EDWARD ROJAS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2056558090
Plan sponsor’s address	1930 EDWARD LAKES ROAD, STE 134, BIRMINGHAM, AL, 35235

Signature of

Role	Plan administrator
Date	2023-05-05
Name of individual signing	EDWARD ROJAS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2056558090
Plan sponsor’s address	1930 EDWARD LAKES ROAD, STE 134, BIRMINGHAM, AL, 35235

Signature of

Role	Plan administrator
Date	2022-06-09
Name of individual signing	EDWARD ROJAS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2056558090
Plan sponsor’s address	1930 EDWARD LAKES ROAD, STE 134, BIRMINGHAM, AL, 35235

Signature of

Role	Plan administrator
Date	2021-06-15
Name of individual signing	EDWARD ROJAS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	2056558090
Plan sponsor’s address	1930 EDWARD LAKES ROAD, STE 134, BIRMINGHAM, AL, 35235

Signature of

Role	Plan administrator
Date	2020-07-21
Name of individual signing	EDWARD ROJAS