Provider Demographics
NPI:1114088812
Name:LONGOS, CATHY EVANS (DMD)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:EVANS
Last Name:LONGOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:22A GLEN ED PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-656-7615
Mailing Address - Fax:
Practice Address - Street 1:22A GLEN ED PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-656-7615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021729122300000X
IL0210016201223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist