Provider Demographics
NPI:1124391347
Name:LONG, DIANA MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LONG
Other - Last Name:PAPPA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:504 NEWBURY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4574
Mailing Address - Country:US
Mailing Address - Phone:256-335-7042
Mailing Address - Fax:
Practice Address - Street 1:504 NEWBURY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-4574
Practice Address - Country:US
Practice Address - Phone:256-335-7042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-18
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL6018122300000X
MS3757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program