Provider Demographics
NPI:1942404249
Name:LONG, LAEL EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAEL
Middle Name:EUGENE
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 1:11 THURSBY LN
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-5120
Mailing Address - Country:US
Mailing Address - Phone:479-876-6775
Mailing Address - Fax:479-876-5063
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8378
Practice Address - Country:US
Practice Address - Phone:918-481-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30231223G0001X
AR34861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice