Provider Demographics
NPI:1326490624
Name:LONG, MARKISHA (RDH)
Entity Type:Individual
Prefix:
First Name:MARKISHA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 GRUBER RD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-8934
Mailing Address - Country:US
Mailing Address - Phone:910-396-1571
Mailing Address - Fax:
Practice Address - Street 1:3718 GRUBER RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-8934
Practice Address - Country:US
Practice Address - Phone:910-396-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902016124124Q00000X
AZH007204124Q00000X
GADH011158124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist