Provider Demographics
NPI:1275527137
Name:LONG, LARRY KEITH (DDS,MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:KEITH
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 JENKS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4311
Mailing Address - Country:US
Mailing Address - Phone:210-667-5171
Mailing Address - Fax:
Practice Address - Street 1:2624 JENKS AVE STE 1
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:210-667-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65381223S0112X
FLDN238061223S0112X, 204E00000X
TX236491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery