Provider Demographics
NPI:1851395727
Name:LONG, THOMAS EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWARD
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 MYRON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3358
Mailing Address - Country:US
Mailing Address - Phone:919-782-6237
Mailing Address - Fax:919-782-7144
Practice Address - Street 1:2310 MYRON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3358
Practice Address - Country:US
Practice Address - Phone:919-782-6237
Practice Address - Fax:919-782-7144
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice