Provider Demographics
NPI:1770652703
Name:LONGFELLOW, ALAN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:LONGFELLOW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:7360 S MCCLINTOCK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5001
Mailing Address - Country:US
Mailing Address - Phone:480-838-6949
Mailing Address - Fax:480-838-0092
Practice Address - Street 1:7360 S MCCLINTOCK DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5001
Practice Address - Country:US
Practice Address - Phone:480-838-6949
Practice Address - Fax:480-838-0092
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15591223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ081274OtherAHCCCS ID
AZ081274OtherPHOENIX HEALTH PLAN ID