Provider Demographics
NPI:1679678668
Name:EDWARD D LONG III DDS PC
Entity type:Organization
Organization Name:EDWARD D LONG III DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-874-6363
Mailing Address - Street 1:1895 SHERIDAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1201
Mailing Address - Country:US
Mailing Address - Phone:716-874-6363
Mailing Address - Fax:716-874-6700
Practice Address - Street 1:1895 SHERIDAN DRIVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14223-1201
Practice Address - Country:US
Practice Address - Phone:716-874-6363
Practice Address - Fax:716-874-6700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty