Healthcare Provider Details

I. General information

NPI: 1598775868
Provider Name (Legal Business Name): WILLIAM RANDALL LONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9602 E WASHINGTON ST SUITE C
INDIANAPOLIS IN
46229-4504
US

IV. Provider business mailing address

9602 E WASHINGTON ST SUITE C
INDIANAPOLIS IN
46229-4504
US

V. Phone/Fax

Practice location:
  • Phone: 317-899-5437
  • Fax: 317-897-0771
Mailing address:
  • Phone: 317-899-5437
  • Fax: 317-897-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12006619
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: