Provider Demographics
NPI:1124376660
Name:LONG, GREGORY GEORGE (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:GEORGE
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 CLIFFORD DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ALMANOR
Mailing Address - State:CA
Mailing Address - Zip Code:96137
Mailing Address - Country:US
Mailing Address - Phone:530-259-4536
Mailing Address - Fax:
Practice Address - Street 1:209 BIRCH STREET
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:CA
Practice Address - Zip Code:96137
Practice Address - Country:US
Practice Address - Phone:530-256-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist