Provider Demographics
NPI:1740589720
Name:TIFFANI A, LONG
Entity Type:Organization
Organization Name:TIFFANI A, LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANI
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:I
Authorized Official - Credentials:MS DDS
Authorized Official - Phone:479-267-5009
Mailing Address - Street 1:181 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-2945
Mailing Address - Country:US
Mailing Address - Phone:479-267-5009
Mailing Address - Fax:
Practice Address - Street 1:181 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-2945
Practice Address - Country:US
Practice Address - Phone:479-267-5009
Practice Address - Fax:479-267-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty