Provider Demographics
NPI:1417176348
Name:LONG, GARY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIAM
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 1:1600 S 4TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2889
Mailing Address - Country:US
Mailing Address - Phone:309-263-2781
Mailing Address - Fax:309-263-4161
Practice Address - Street 1:1600 S 4TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2889
Practice Address - Country:US
Practice Address - Phone:309-263-2781
Practice Address - Fax:309-263-4161
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice