Provider Demographics
NPI:1205090040
Name:LONGINO, JAMAAL EDWIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMAAL
Middle Name:EDWIN
Last Name:LONGINO
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 1:105 RIDGE WAY
Mailing Address - Street 2:STE
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-3303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 RIDGE WAY
Practice Address - Street 2:STE
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3303
Practice Address - Country:US
Practice Address - Phone:601-203-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3483-08122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist