Provider Demographics
NPI:1942529425
Name:MUGIANTO, LONG (DMD)
Entity Type:Individual
Prefix:DR
First Name:LONG
Middle Name:
Last Name:MUGIANTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 SIENNA CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5242
Mailing Address - Country:US
Mailing Address - Phone:267-997-8476
Mailing Address - Fax:
Practice Address - Street 1:3400 LOMBARDY LN STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-3315
Practice Address - Country:US
Practice Address - Phone:214-350-5333
Practice Address - Fax:214-350-8555
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2012-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038251122300000X
TX27450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist