Basic Information
| Provider Information | |||||||||
| NPI: | 1598113011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BROSMER | ||||||||
| OtherFirstName: | LAUREN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5430 E WASHINGTON ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462196446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173221840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 RILEY HOSPITAL DR STE 4205 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179449604 | ||||||||
| FaxNumber: | 3179480760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 12012496A | IN | N | Dental Providers | Dentist | 1223P0221X | 12012496A | IN | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.