Healthcare Provider Details

I. General information

NPI: 1740259415
Provider Name (Legal Business Name): STEVEN K LONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 NW KINGS BLVD
CORVALLIS OR
97330
US

IV. Provider business mailing address

2318 NW KINGS BLVD
CORVALLIS OR
97330
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-6116
  • Fax: 541-753-3616
Mailing address:
  • Phone: 541-754-6116
  • Fax: 541-753-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD54041
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: