Provider Demographics
NPI:1033356803
Name:LONG, TONYA MONIQUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TONYA
Middle Name:MONIQUE
Last Name:LONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 CEDAR GLADE RD
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3630
Mailing Address - Country:US
Mailing Address - Phone:314-304-0897
Mailing Address - Fax:
Practice Address - Street 1:1025 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-2079
Practice Address - Country:US
Practice Address - Phone:573-431-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006021256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist