Provider Demographics
NPI:1053530873
Name:LONG, LARRY I (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:I
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 HAMMONTREE CT
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-2529
Mailing Address - Country:US
Mailing Address - Phone:515-987-4400
Mailing Address - Fax:
Practice Address - Street 1:7029 VISTA DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-9311
Practice Address - Country:US
Practice Address - Phone:515-222-1244
Practice Address - Fax:515-222-4466
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA69901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice