Provider Demographics
NPI:1083882716
Name:LONGO DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:LONGO DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-738-7210
Mailing Address - Street 1:1037 BEACON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5640
Mailing Address - Country:US
Mailing Address - Phone:617-738-7210
Mailing Address - Fax:617-738-2930
Practice Address - Street 1:1037 BEACON ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5640
Practice Address - Country:US
Practice Address - Phone:617-738-7210
Practice Address - Fax:617-738-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA00171811223G0001X
MA213901223G0001X
MA184321223P0300X
MA174151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty