Healthcare Provider Details

I. General information

NPI: 1063775492
Provider Name (Legal Business Name): JUSTIN LONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 CLEVELAND RD W
HURON OH
44839-1021
US

IV. Provider business mailing address

3307 CLEVELAND RD W
HURON OH
44839-1021
US

V. Phone/Fax

Practice location:
  • Phone: 567-623-7611
  • Fax:
Mailing address:
  • Phone: 567-623-7611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-023747
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: