Provider Demographics
NPI:1841248945
Name:LONG, GARRETT ISAAC III (DDS)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:ISAAC
Last Name:LONG
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 92A11
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:WV
Mailing Address - Zip Code:26704-9728
Mailing Address - Country:US
Mailing Address - Phone:304-496-7750
Mailing Address - Fax:
Practice Address - Street 1:17978 SR 55
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:WV
Practice Address - Zip Code:26801
Practice Address - Country:US
Practice Address - Phone:304-897-5915
Practice Address - Fax:304-897-6216
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2832122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist