Provider Demographics
NPI:1982993085
Name:LONG, REBECCA MYNETTE (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MYNETTE
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2057
Mailing Address - Country:US
Mailing Address - Phone:304-344-4430
Mailing Address - Fax:304-345-4801
Practice Address - Street 1:871 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2057
Practice Address - Country:US
Practice Address - Phone:304-344-4430
Practice Address - Fax:304-345-4801
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist