Provider Demographics
NPI:1659864023
Name:LONG, ALLIE NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALLIE
Middle Name:NICOLE
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ALLIE
Other - Middle Name:NICOLE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:890 EASTLAKE PARKWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914
Mailing Address - Country:US
Mailing Address - Phone:619-421-2828
Mailing Address - Fax:
Practice Address - Street 1:890 EASTLAKE PARKWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914
Practice Address - Country:US
Practice Address - Phone:619-421-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice