Provider Demographics
NPI:1134167315
Name:LONG, DAVID GLENN (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLENN
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 1:1697 142ND AVE
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9426
Mailing Address - Country:US
Mailing Address - Phone:616-681-9943
Mailing Address - Fax:
Practice Address - Street 1:1697 142ND AVE
Practice Address - Street 2:
Practice Address - City:DORR
Practice Address - State:MI
Practice Address - Zip Code:49323-9426
Practice Address - Country:US
Practice Address - Phone:616-681-9943
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0151701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice