Provider Demographics
NPI:1710335401
Name:LONG, JACOB DANIEL (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SAINT CHARLES ST STE 6
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9172
Mailing Address - Country:US
Mailing Address - Phone:812-482-7668
Mailing Address - Fax:
Practice Address - Street 1:1950 SAINT CHARLES ST STE 6
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-9172
Practice Address - Country:US
Practice Address - Phone:812-482-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1202497A1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics