Provider Demographics
NPI:1306865647
Name:LONG, C. ROSS (DDS)
Entity Type:Individual
Prefix:MR
First Name:C. ROSS
Middle Name:
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 1:3740 COORS BLVD NW STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4762
Mailing Address - Country:US
Mailing Address - Phone:505-836-1280
Mailing Address - Fax:505-839-4782
Practice Address - Street 1:3740 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4762
Practice Address - Country:US
Practice Address - Phone:505-836-1280
Practice Address - Fax:505-839-4782
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist