Provider Demographics
NPI:1750781886
Name:LONGO, PETER CHARLES (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:LONGO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-4219
Mailing Address - Country:US
Mailing Address - Phone:308-293-0488
Mailing Address - Fax:
Practice Address - Street 1:1207 17TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-4219
Practice Address - Country:US
Practice Address - Phone:308-293-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE70461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics