Healthcare Provider Details

I. General information

NPI: 1912077546
Provider Name (Legal Business Name): RYAN R LONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13820 SAINT AUGUSTINE RD STE 105
JACKSONVILLE FL
32258-5424
US

IV. Provider business mailing address

926 GREAT POND DR SUITE 4000
ALTAMONTE SPRINGS FL
32714-7244
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-7700
  • Fax: 904-260-7733
Mailing address:
  • Phone: 407-772-5124
  • Fax: 407-788-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN17052
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: