Healthcare Provider Details

I. General information

NPI: 1689676017
Provider Name (Legal Business Name): THOMAS JAMES LONGWILL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W TILDEN ST
ROSWELL NM
88203-4544
US

IV. Provider business mailing address

306 W TILDEN ST
ROSWELL NM
88203-4544
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-3204
  • Fax: 575-625-2071
Mailing address:
  • Phone: 575-623-3204
  • Fax: 575-625-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1528
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: