Provider Demographics
NPI:1487184248
Name:LONG, ALEX (DMD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:LONG
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 1:229 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5434
Mailing Address - Country:US
Mailing Address - Phone:920-332-6691
Mailing Address - Fax:
Practice Address - Street 1:1805 W WHITE OAK TER STE A
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3456
Practice Address - Country:US
Practice Address - Phone:414-840-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001538-151223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice