Provider Demographics
NPI:1700997616
Name:LONG FAMILY DENTAL PA
Entity Type:Organization
Organization Name:LONG FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-645-2437
Mailing Address - Street 1:907 W HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033
Mailing Address - Country:US
Mailing Address - Phone:817-645-2437
Mailing Address - Fax:817-645-3961
Practice Address - Street 1:907 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033
Practice Address - Country:US
Practice Address - Phone:817-645-2437
Practice Address - Fax:817-645-3961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty