Provider Demographics
NPI:1356493829
Name:LONG, JERROD D (DDS)
Entity type:Individual
Prefix:DR
First Name:JERROD
Middle Name:D
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:#2 NACO ROAD
Mailing Address - Street 2:BOX 1898
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-2898
Mailing Address - Country:US
Mailing Address - Phone:520-432-5371
Mailing Address - Fax:520-432-6658
Practice Address - Street 1:#2 NACO ROAD
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-2898
Practice Address - Country:US
Practice Address - Phone:520-432-5370
Practice Address - Fax:520-432-6658
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice