Provider Demographics
NPI:1659459667
Name:LONG, ROBERT W (DDS MSD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS MSD
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Mailing Address - Street 1:2705 S BERKLEY
Mailing Address - Street 2:BUILDING 2 SUITE B
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8007
Mailing Address - Country:US
Mailing Address - Phone:765-453-2267
Mailing Address - Fax:765-453-1150
Practice Address - Street 1:2705 S BERKLEY
Practice Address - Street 2:BUILDING 2 SUITE B
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8007
Practice Address - Country:US
Practice Address - Phone:765-453-2267
Practice Address - Fax:765-453-1150
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN12010170A1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12010170AOtherDENTAL LICENSE