Healthcare Provider Details

I. General information

NPI: 1982723656
Provider Name (Legal Business Name): ALFRED T LONGO DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N 144TH ST SUITE A
OMAHA NE
68154-4715
US

IV. Provider business mailing address

1710 N 144TH ST SUITE A
OMAHA NE
68154-4715
US

V. Phone/Fax

Practice location:
  • Phone: 402-431-9446
  • Fax: 402-493-5975
Mailing address:
  • Phone: 402-496-9733
  • Fax: 402-493-5975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4694
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: