Provider Demographics
NPI:1760936181
Name:LONG, DORIAN
Entity Type:Individual
Prefix:DR
First Name:DORIAN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6908 COLLEYVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6244
Mailing Address - Country:US
Mailing Address - Phone:682-503-4507
Mailing Address - Fax:
Practice Address - Street 1:6908 COLLEYVILLE BLVD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6244
Practice Address - Country:US
Practice Address - Phone:682-503-4507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist