Provider Demographics
NPI:1346617313
Name:LONGAN, GENTRY REBECCA (DMD)
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:REBECCA
Last Name:LONGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:GENTRY
Other - Middle Name:REBECCA
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1001 S 41ST ST E
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-6253
Mailing Address - Country:US
Mailing Address - Phone:918-687-0201
Mailing Address - Fax:
Practice Address - Street 1:1001 S 41ST ST E
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-6253
Practice Address - Country:US
Practice Address - Phone:918-687-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist