Provider Demographics
NPI:1467571729
Name:LONG PRAIRIE DENTAL
Entity Type:Organization
Organization Name:LONG PRAIRIE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KANEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-513-1300
Mailing Address - Street 1:3405 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-2737
Mailing Address - Country:US
Mailing Address - Phone:214-513-1300
Mailing Address - Fax:214-513-1311
Practice Address - Street 1:3405 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-2737
Practice Address - Country:US
Practice Address - Phone:214-513-1300
Practice Address - Fax:214-513-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200621223G0001X
TX223171223G0001X
TX224271223G0001X
TX221681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID