Provider Demographics
NPI:1821475633
Name:CRAIG C. LONGENECKER DDS PA
Entity Type:Organization
Organization Name:CRAIG C. LONGENECKER DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LONGENECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-904-7836
Mailing Address - Street 1:16928 YORK RD
Mailing Address - Street 2:
Mailing Address - City:MONKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21111-1042
Mailing Address - Country:US
Mailing Address - Phone:410-357-0099
Mailing Address - Fax:
Practice Address - Street 1:16928 YORK RD
Practice Address - Street 2:
Practice Address - City:MONKTON
Practice Address - State:MD
Practice Address - Zip Code:21111-1042
Practice Address - Country:US
Practice Address - Phone:410-357-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11730OtherDENTAL LICENSEE
MD1932381977OtherPERSONAL NPI NUMBER