Provider Demographics
NPI:1467043729
Name:LONG, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 AUTUMN HL
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4436
Mailing Address - Country:US
Mailing Address - Phone:214-952-5143
Mailing Address - Fax:
Practice Address - Street 1:313 AUTUMN HL
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4436
Practice Address - Country:US
Practice Address - Phone:214-952-5143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
TX12656124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental Hygienist
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty