Provider Demographics
NPI:1255429015
Name:LONG, EULESS HARRISON JR (DMD)
Entity type:Individual
Prefix:DR
First Name:EULESS
Middle Name:HARRISON
Last Name:LONG
Suffix:JR
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 1:760 WINDING WOOD DR
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1681
Mailing Address - Country:US
Mailing Address - Phone:334-514-0763
Mailing Address - Fax:
Practice Address - Street 1:25 CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-1258
Practice Address - Country:US
Practice Address - Phone:334-567-2828
Practice Address - Fax:334-567-5434
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4856OtherSTATE LICENSE
AL412037566OtherTIN