Provider Demographics
NPI:1750316725
Name:DAVID SCOTT LONG DMD LLC
Entity type:Organization
Organization Name:DAVID SCOTT LONG DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LLC MANAGER & PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD LLC
Authorized Official - Phone:334-712-1224
Mailing Address - Street 1:1290 WESTGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2153
Mailing Address - Country:US
Mailing Address - Phone:334-712-1224
Mailing Address - Fax:334-712-0050
Practice Address - Street 1:1290 WESTGATE PKWY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2153
Practice Address - Country:US
Practice Address - Phone:334-712-1224
Practice Address - Fax:334-712-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4527122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
018149OtherUNITED CONCORDIA
FL143852OtherCIGNA DENTAL HMO PLAN
20580OtherBCBS ALABAMA