Provider Demographics
NPI:1932602661
Name:W.ROGER LONG DDS.,P.A.
Entity Type:Organization
Organization Name:W.ROGER LONG DDS.,P.A.
Other - Org Name:SMOOTH SAILING DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:W.ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-464-2943
Mailing Address - Street 1:1511 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4779
Mailing Address - Country:US
Mailing Address - Phone:772-464-2943
Mailing Address - Fax:772-464-8801
Practice Address - Street 1:1511 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4779
Practice Address - Country:US
Practice Address - Phone:772-464-2943
Practice Address - Fax:772-464-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL96631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty