Provider Demographics
NPI:1518130228
Name:LONG, TIFFANI ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIFFANI
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TIFFANI
Other - Middle Name:ANN
Other - Last Name:COTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:181 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-2945
Mailing Address - Country:US
Mailing Address - Phone:661-345-4578
Mailing Address - Fax:
Practice Address - Street 1:181 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-2945
Practice Address - Country:US
Practice Address - Phone:661-345-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR36501223G0001X
CA477051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice