1295830537 NPI number — DR. JULIE WATHEN LONG DDS PA

Table of content: DR. JULIE WATHEN LONG DDS PA (NPI 1295830537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295830537 NPI number — DR. JULIE WATHEN LONG DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
JULIE
Provider Middle Name:
WATHEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295830537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 WEST GRAND PARKWAY
Provider Second Line Business Mailing Address:
#1200
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 WEST GRAND PARKWAY
Provider Second Line Business Practice Location Address:
#1200
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-395-1700
Provider Business Practice Location Address Fax Number:
281-395-1725
Provider Enumeration Date:
09/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  18753 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)