Provider Demographics
NPI:1760452551
Name:LONG, RICHARD G (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
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 1:46 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-3217
Mailing Address - Country:US
Mailing Address - Phone:910-353-3535
Mailing Address - Fax:910-353-9754
Practice Address - Street 1:46 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-3217
Practice Address - Country:US
Practice Address - Phone:910-353-3535
Practice Address - Fax:910-353-9754
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9018POtherBCBSNC
NC899018PMedicaid
1749169OtherUNITED CONCORDIA
NC899018PMedicaid
855RMedicare UPIN