Provider Demographics
NPI:1649323379
Name:LONG, KENT CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:CHARLES
Last Name:LONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4978 NORTHCUTT PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-3840
Mailing Address - Country:US
Mailing Address - Phone:937-278-7246
Mailing Address - Fax:937-278-5640
Practice Address - Street 1:4978 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3840
Practice Address - Country:US
Practice Address - Phone:937-278-7246
Practice Address - Fax:937-278-5640
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1362111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4071931Medicare ID - Type Unspecified
OHU89456Medicare UPIN