Healthcare Provider Details

I. General information

NPI: 1215365283
Provider Name (Legal Business Name): JEREMIAH LONG DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHERRY ST
MILFORD CT
06460-3482
US

IV. Provider business mailing address

1 CHERRY ST
MILFORD CT
06460-3482
US

V. Phone/Fax

Practice location:
  • Phone: 203-878-4757
  • Fax: 203-874-9253
Mailing address:
  • Phone: 203-878-4757
  • Fax: 203-874-9253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMIAH LONG
Title or Position: OWNER
Credential: D.M.D.
Phone: 203-878-4757