Healthcare Provider Details

I. General information

NPI: 1306989751
Provider Name (Legal Business Name): NICHOLAS CLAYTON LONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 THE ALAMEDA
SAN JOSE CA
95126
US

IV. Provider business mailing address

872 THE ALAMEDA
SAN JOSE CA
95126
US

V. Phone/Fax

Practice location:
  • Phone: 408-947-8444
  • Fax: 408-947-7978
Mailing address:
  • Phone: 408-947-8444
  • Fax: 408-947-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number44927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: