Provider Demographics
NPI:1558093211
Name:LONG, REBECCA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-5539
Mailing Address - Country:US
Mailing Address - Phone:562-242-8244
Mailing Address - Fax:
Practice Address - Street 1:432 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5613
Practice Address - Country:US
Practice Address - Phone:928-636-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0114781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice