Provider Demographics
NPI:1689833998
Name:LONG, TANYA L (DMD)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-1368
Mailing Address - Country:US
Mailing Address - Phone:800-787-2812
Mailing Address - Fax:877-370-6515
Practice Address - Street 1:901 S 15TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-1368
Practice Address - Country:US
Practice Address - Phone:800-787-2812
Practice Address - Fax:877-370-6515
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8599122300000X, 1223G0001X
IN12011588A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist