Provider Demographics
NPI:1013076389
Name:LONG, GREGORY WILLIAM (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:LONG
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 1:306 WEST SOLOMON CT
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063
Mailing Address - Country:US
Mailing Address - Phone:724-453-0622
Mailing Address - Fax:
Practice Address - Street 1:207 EMERSON DRIVE
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063
Practice Address - Country:US
Practice Address - Phone:724-452-7887
Practice Address - Fax:724-452-6803
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029696L122300000X
FLDN16563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist