Provider Demographics
NPI:1184635203
Name:LONG, HAROLD MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:MICHAEL
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 1:211 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3633
Mailing Address - Country:US
Mailing Address - Phone:931-455-2595
Mailing Address - Fax:931-455-4728
Practice Address - Street 1:211 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3633
Practice Address - Country:US
Practice Address - Phone:931-455-2595
Practice Address - Fax:931-455-4728
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12OtherDENTIST