Provider Demographics
NPI:1922475458
Name:LONG, AUDRA (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 ROCKRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-8009
Mailing Address - Country:US
Mailing Address - Phone:920-716-1513
Mailing Address - Fax:
Practice Address - Street 1:1510 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4102
Practice Address - Country:US
Practice Address - Phone:920-261-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001200 - 151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics