Provider Demographics
NPI:1811050313
Name:LONG FAMILY DENTISTRY INC
Entity type:Organization
Organization Name:LONG FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LONG
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-627-2565
Mailing Address - Street 1:POST OFFICE BOX 291
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614
Mailing Address - Country:US
Mailing Address - Phone:662-627-2565
Mailing Address - Fax:662-627-2524
Practice Address - Street 1:527 DESOTO AVENUE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-627-2565
Practice Address - Fax:662-627-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS186980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064885Medicaid