Healthcare Provider Details

I. General information

NPI: 1508075599
Provider Name (Legal Business Name): DAVID LYNTON LONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SE MILWAUKIE AVE
PORTLAND OR
97202-5417
US

IV. Provider business mailing address

6200 SE MILWAUKIE AVE
PORTLAND OR
97202-5417
US

V. Phone/Fax

Practice location:
  • Phone: 503-235-0054
  • Fax: 503-235-7258
Mailing address:
  • Phone: 503-235-0054
  • Fax: 503-235-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4247
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: