Provider Demographics
NPI:1154454692
Name:LONG, DENNIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 DEAN ST
Mailing Address - Street 2:SUITE O-1
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1066
Mailing Address - Country:US
Mailing Address - Phone:630-377-7660
Mailing Address - Fax:
Practice Address - Street 1:2210 DEAN ST
Practice Address - Street 2:SUITE O-1
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1066
Practice Address - Country:US
Practice Address - Phone:630-377-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36425822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C38223Medicare UPIN
457922Medicare PIN