Provider Demographics
NPI:1184635849
Name:LONGOBARDI, MARK LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:LONGOBARDI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2428
Mailing Address - Country:US
Mailing Address - Phone:860-456-1784
Mailing Address - Fax:860-423-6408
Practice Address - Street 1:169 VALLEY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2428
Practice Address - Country:US
Practice Address - Phone:860-456-1784
Practice Address - Fax:860-423-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice