Healthcare Provider Details

I. General information

NPI: 1568784882
Provider Name (Legal Business Name): JERRY J LONG DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 CALDWELL DR
HAZLEHURST MS
39083-2723
US

IV. Provider business mailing address

PO BOX 587
HAZLEHURST MS
39083-0587
US

V. Phone/Fax

Practice location:
  • Phone: 601-894-4732
  • Fax: 601-894-4732
Mailing address:
  • Phone: 601-894-4732
  • Fax: 607-894-4732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number925-59
License Number StateMS

VIII. Authorized Official

Name: DR. JERRY J LONG
Title or Position: PRESIDENT
Credential: DDS
Phone: 601-894-4732