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General NPI Number Information
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NPI Number | 1922475458
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Entity Type | Individual
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Provider Name | AUDRA LONG DDS, MS
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Gender | Female
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Dates
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Enumeration Date | 09/01/2015
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Last Update Date | 09/01/2015
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Provider Practice Location Address
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Address Line | 1510 DOCTORS CT
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City | WATERTOWN
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State | WI
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Zip | 53094-4102
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Country | US
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Telephone | 920-261-3560
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Fax |
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Provider Business Mailing Address
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Address Line | 1520 ROCKRIDGE WAY
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City | WAUKESHA
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State | WI
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Zip | 53188-8009
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Country | US
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Telephone | 920-716-1513
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 1001200 - 15
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License Number State | WI
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