Provider Demographics
NPI:1689833998
Name:LONG, TANYA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4139
Mailing Address - Country:US
Mailing Address - Phone:812-725-7500
Mailing Address - Fax:812-725-7510
Practice Address - Street 1:802 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4139
Practice Address - Country:US
Practice Address - Phone:812-725-7500
Practice Address - Fax:812-725-7510
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY85991223G0001X
IN12011588A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice