Provider Demographics
NPI:1336278282
Name:LONGO, VINCENT (DMD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:LONGO
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 1:2300 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 4-A
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1392
Mailing Address - Country:US
Mailing Address - Phone:302-654-7362
Mailing Address - Fax:302-654-1070
Practice Address - Street 1:2300 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 4-A
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1392
Practice Address - Country:US
Practice Address - Phone:302-654-7362
Practice Address - Fax:302-654-1070
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00011231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice