=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669692349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER R. LONG D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 FARMFIELD AVE STE E
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-7756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-766-0112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 846 SAINT ANDREWS BLVD STE C
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-7148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-225-9002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 3707
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------