Provider Demographics
NPI:1689155608
Name:LONGO, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:LONGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WURTSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12790-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WURTSBORO
Practice Address - State:NY
Practice Address - Zip Code:12790-2153
Practice Address - Country:US
Practice Address - Phone:917-380-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist