Healthcare Provider Details

I. General information

NPI: 1407954852
Provider Name (Legal Business Name): DENNIS R. LONG, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E CHAPMAN AVE
ORANGE CA
92869-3206
US

IV. Provider business mailing address

PO BOX 68
NORCO CA
92860-0068
US

V. Phone/Fax

Practice location:
  • Phone: 951-532-5005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number00G472430
License Number StateCA

VIII. Authorized Official

Name: MRS. SANDI WILLIAMSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 951-532-5005