Healthcare Provider Details

I. General information

NPI: 1245094358
Provider Name (Legal Business Name): OLIVIA LONGHOUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2329 N TRIPHAMMER RD
ITHACA NY
14850-1011
US

IV. Provider business mailing address

2329 N TRIPHAMMER RD
ITHACA NY
14850-1011
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-0060
  • Fax:
Mailing address:
  • Phone: 607-257-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number065141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: