Provider Demographics
NPI:1780043018
Name:ROBERT D. LONG DDS, PA
Entity Type:Organization
Organization Name:ROBERT D. LONG DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:913-491-3353
Mailing Address - Street 1:11111 NALL AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1625
Mailing Address - Country:US
Mailing Address - Phone:913-491-3353
Mailing Address - Fax:913-491-1042
Practice Address - Street 1:11111 NALL AVE STE 109
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1625
Practice Address - Country:US
Practice Address - Phone:913-491-3353
Practice Address - Fax:913-491-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 6019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty