Provider Demographics
NPI:1952924961
Name:LONG, DENNIS (DHSC, CCP)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:DHSC, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3310
Practice Address - Country:US
Practice Address - Phone:847-722-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL214000255242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty