Provider Demographics
NPI:1760164701
Name:LONG, CAMERON ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:ALLEN
Last Name:LONG
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 1:10176 VIA COLOMBA CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-6549
Mailing Address - Country:US
Mailing Address - Phone:913-549-6700
Mailing Address - Fax:
Practice Address - Street 1:1701 BOY SCOUT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2173
Practice Address - Country:US
Practice Address - Phone:913-549-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL283041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice