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General NPI Number Information
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NPI Number | 1124391347
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Entity Type | Individual
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Provider Name | DIANA MARIE LONG DDS
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Gender | Female
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Dates
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Enumeration Date | 02/18/2012
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Last Update Date | 11/28/2016
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Provider Practice Location Address
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Address Line | 504 NEWBURY DR
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City | MADISON
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State | MS
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Zip | 39110-4574
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Country | US
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Telephone | 256-335-7042
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Fax |
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Provider Business Mailing Address
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Address Line | 504 NEWBURY DR
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City | MADISON
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State | MS
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Zip | 39110-4574
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Country | US
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Telephone | 256-335-7042
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6018
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3757
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License Number State | MS
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