Healthcare Provider Details

I. General information

NPI: 1518130228
Provider Name (Legal Business Name): TIFFANI ANN LONG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANI ANN COTTER DDS

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W MAIN ST
FARMINGTON AR
72730-2945
US

IV. Provider business mailing address

181 W MAIN ST
FARMINGTON AR
72730-2945
US

V. Phone/Fax

Practice location:
  • Phone: 661-345-4578
  • Fax:
Mailing address:
  • Phone: 661-345-4578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3650
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number47705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: