Provider Demographics
NPI:1598775868
Name:LONG, WILLIAM RANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RANDALL
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:9602 E WASHINGTON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-4504
Mailing Address - Country:US
Mailing Address - Phone:317-899-5437
Mailing Address - Fax:317-897-0771
Practice Address - Street 1:9602 E WASHINGTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-4504
Practice Address - Country:US
Practice Address - Phone:317-899-5437
Practice Address - Fax:317-897-0771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN120066191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN429256OtherUNITED CONCORDIA
IN145620OtherCSHCS