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General NPI Number Information
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NPI Number | 1093294076
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Entity Type | Organization
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Legal Business Name | JACOB R. LONG, DDS, PLLC
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Dates
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Enumeration Date | 08/09/2018
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Last Update Date | 08/09/2018
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Provider Practice Location Address
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Address Line | 736 MEDICAL CENTER DR STE 101
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City | WILMINGTON
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State | NC
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Zip | 28401-4284
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Country | US
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Telephone | 910-762-0255
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Fax |
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Provider Business Mailing Address
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Address Line | 736 MEDICAL CENTER DR STE 101
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City | WILMINGTON
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State | NC
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Zip | 28401-4284
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. JACOB R. LONG
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Credential | DDS
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Telephone | 910-762-0355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 10411
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License Number State | NC
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