Healthcare Provider Details

I. General information

NPI: 1063410462
Provider Name (Legal Business Name): DR. W ROGER LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 S 25TH ST SUITE A
FORT PIERCE FL
34947-4779
US

IV. Provider business mailing address

1511 S 25TH ST SUITE A
FORT PIERCE FL
34947-4779
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-2943
  • Fax: 772-464-8801
Mailing address:
  • Phone: 772-464-2943
  • Fax: 772-464-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN0009663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: