Healthcare Provider Details

I. General information

NPI: 1710335401
Provider Name (Legal Business Name): JACOB DANIEL LONG DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SAINT CHARLES ST STE 6
JASPER IN
47546-9172
US

IV. Provider business mailing address

1950 SAINT CHARLES ST STE 6
JASPER IN
47546-9172
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-7668
  • Fax:
Mailing address:
  • Phone: 812-482-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1202497A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: