Provider Demographics
NPI:1720205107
Name:LONG, ELIZABETH ANN (DDS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3421 W WILLIAM CANNON DR
Mailing Address - Street 2:SUITE 143
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5000
Mailing Address - Country:US
Mailing Address - Phone:512-892-5511
Mailing Address - Fax:512-892-2061
Practice Address - Street 1:3421 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE 143
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5000
Practice Address - Country:US
Practice Address - Phone:512-892-5511
Practice Address - Fax:512-892-2061
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX121291223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics