Provider Demographics
NPI:1750663605
Name:LONGINO, WILLIAM S (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:S
Last Name:LONGINO
Suffix:
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 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:1600 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-2261
Practice Address - Country:US
Practice Address - Phone:254-313-4200
Practice Address - Fax:254-313-4531
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX270801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice