1750316725 NPI number — DAVID SCOTT LONG DMD LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750316725 NPI number — DAVID SCOTT LONG DMD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID SCOTT LONG DMD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1750316725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 WESTGATE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303-2153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-712-1224
Provider Business Mailing Address Fax Number:
334-712-0050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 WESTGATE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-712-1224
Provider Business Practice Location Address Fax Number:
334-712-0050
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
LLC MANAGER & PRESIDENT
Authorized Official Telephone Number:
334-712-1224

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4527 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018149 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 143852 . This is a "CIGNA DENTAL HMO PLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 20580 . This is a "BCBS ALABAMA" identifier . This identifiers is of the category "OTHER".




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