MEDICARE: DR. W ROGER LONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN0009663	FL

General Provider Information

NPI Number	:	1063410462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. W ROGER LONG

Provider Business Mailing Address
First Line	:	1511 S 25TH ST
Second Line	:	SUITE A
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4779
Country	:	US
Telephone Number	:	772-464-2943
Fax Number	:	772-464-8801

Provider Business Practice Location Address
First Line	:	1511 S 25TH ST
Second Line	:	SUITE A
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4779
Country	:	US
Telephone Number	:	772-464-2943
Fax Number	:	772-464-8801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2005
Last Update Date	:	07/08/2007

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