Provider Demographics
NPI:1689676017
Name:LONGWILL, THOMAS JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:LONGWILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W TILDEN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4544
Mailing Address - Country:US
Mailing Address - Phone:575-623-3204
Mailing Address - Fax:575-625-2071
Practice Address - Street 1:306 W TILDEN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4544
Practice Address - Country:US
Practice Address - Phone:575-623-3204
Practice Address - Fax:575-625-2071
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM15281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0016994Medicaid
NM851955OtherPROVIDER ID