Provider Demographics
NPI:1215365283
Name:JEREMIAH LONG DMD PC
Entity Type:Organization
Organization Name:JEREMIAH LONG DMD PC
Other - Org Name:LIFE LONG DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-878-4757
Mailing Address - Street 1:1 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3482
Mailing Address - Country:US
Mailing Address - Phone:203-878-4757
Mailing Address - Fax:203-874-9253
Practice Address - Street 1:1 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3482
Practice Address - Country:US
Practice Address - Phone:203-878-4757
Practice Address - Fax:203-874-9253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty