Provider Demographics
NPI:1295474500
Name:LONG, RACHEAL MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:RACHEAL
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:RACHEAL
Other - Middle Name:MARIE
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2133 PEPPERRELL ST BLDG 3352
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:210-292-9053
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST BLDG 3352
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-9053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist