Provider Demographics
NPI:1598113011
Name:LONG, LAUREN (DDS)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:BROSMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5430 E WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6446
Mailing Address - Country:US
Mailing Address - Phone:317-322-1840
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR STE 4205
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-944-9604
Practice Address - Fax:317-948-0760
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012496A122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist