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General NPI Number Information
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NPI Number | 1568784882
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Entity Type | Organization
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Legal Business Name | JERRY J LONG DDS PA
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Dates
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Enumeration Date | 03/01/2010
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Last Update Date | 03/01/2010
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Provider Practice Location Address
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Address Line | 240 CALDWELL DR
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City | HAZLEHURST
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State | MS
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Zip | 39083-2723
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Country | US
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Telephone | 601-894-4732
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Fax | 601-894-4732
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Provider Business Mailing Address
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Address Line | PO BOX 587
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City | HAZLEHURST
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State | MS
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Zip | 39083-0587
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Country | US
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Telephone | 601-894-4732
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Fax | 607-894-4732
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY J LONG
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Credential | DDS
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Telephone | 601-894-4732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 925-59
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License Number State | MS
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