Provider Demographics
NPI:1265503585
Name:LONG, BRIAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
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 1:22100 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3932
Mailing Address - Country:US
Mailing Address - Phone:313-563-5855
Mailing Address - Fax:313-563-5865
Practice Address - Street 1:22100 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3932
Practice Address - Country:US
Practice Address - Phone:313-563-5855
Practice Address - Fax:313-563-5865
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0162161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice