Provider Demographics
NPI:1265448393
Name:LONG, WILLIAM B (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:B
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:308 N TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4022
Mailing Address - Country:US
Mailing Address - Phone:919-735-6017
Mailing Address - Fax:919-735-7366
Practice Address - Street 1:308 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-4022
Practice Address - Country:US
Practice Address - Phone:919-735-6017
Practice Address - Fax:919-735-7366
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC54491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995376Medicaid
NC8995376Medicaid