Provider Demographics
NPI:1710170980
Name:LONG, MARTIN KNOX SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:KNOX
Last Name:LONG
Suffix:SR
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 1:4841 HIXSON PIKE STE G
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4431
Mailing Address - Country:US
Mailing Address - Phone:423-877-2043
Mailing Address - Fax:
Practice Address - Street 1:4841 HIXSON PIKE STE G
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4431
Practice Address - Country:US
Practice Address - Phone:423-877-2043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS29181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice