Healthcare Provider Details

I. General information

NPI: 1841248945
Provider Name (Legal Business Name): GARRETT ISAAC LONG III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17978 SR 55
BAKER WV
26801
US

IV. Provider business mailing address

RR 1 BOX 92A11
AUGUSTA WV
26704-9728
US

V. Phone/Fax

Practice location:
  • Phone: 304-897-5915
  • Fax: 304-897-6216
Mailing address:
  • Phone: 304-496-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2832
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: