Healthcare Provider Details

I. General information

NPI: 1689886640
Provider Name (Legal Business Name): EDWARD A LONGWE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW SUITE 2-B
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

24805 PINEBROOK RD SUITE 100
CHANTILLY VA
20152-4126
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-1491
  • Fax:
Mailing address:
  • Phone: 703-327-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN1000625
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: