Basic Information
| Provider Information | |||||||||
| NPI: | 1124376660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 CLIFFORD DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ALMANOR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302594536 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 209 BIRCH STREET | ||||||||
| Address2: | |||||||||
| City: | WESTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302563152 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 21475 | CA | Y | Dental Providers | Dentist |
No ID Information.