Healthcare Provider Details

I. General information

NPI: 1295270916
Provider Name (Legal Business Name): VERONICA LONGVILLE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 PINEDALE RD
GREENSBORO NC
27408-4713
US

IV. Provider business mailing address

4601 ADONICA LN
GREENSBORO NC
27410-9658
US

V. Phone/Fax

Practice location:
  • Phone: 336-379-8377
  • Fax:
Mailing address:
  • Phone: 210-621-3713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12089
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: