Provider Demographics
NPI:1437787744
Name:LONGO, BENJAMIN (DMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LONGO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 US HIGHWAY 70 E
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-6857
Mailing Address - Country:US
Mailing Address - Phone:252-638-3600
Mailing Address - Fax:
Practice Address - Street 1:1702 US HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-6857
Practice Address - Country:US
Practice Address - Phone:252-638-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC122041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program