Provider Demographics
NPI:1629563291
Name:LONG, KEELY E (DDS)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:E
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 1:301 E CEVALLOS APT 443
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1979
Mailing Address - Country:US
Mailing Address - Phone:469-878-9945
Mailing Address - Fax:
Practice Address - Street 1:8338 N LOOP 1604 W STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3482
Practice Address - Country:US
Practice Address - Phone:210-465-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice