Provider Demographics
NPI:1821624347
Name:LONG, CAITLYN STOUDER (DMD)
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:STOUDER
Last Name:LONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:706-364-7042
Mailing Address - Fax:
Practice Address - Street 1:655 SOUTH 7TH STREET BLDG 700/700-A
Practice Address - Street 2:78 MDG/SGXD
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-327-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN016060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program