MEDICARE: DR. LARRY KEITH LONG DDS,MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	6538	NC
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN23806	FL
3	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	DN23806	FL
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	23649	TX

General Provider Information

NPI Number	:	1275527137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY KEITH LONG DDS,MD

Provider Business Mailing Address
First Line	:	2624 JENKS AVE STE 1
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4311
Country	:	US
Telephone Number	:	210-667-5171
Fax Number	:

Provider Business Practice Location Address
First Line	:	2624 JENKS AVE STE 1
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405
Country	:	US
Telephone Number	:	210-667-5171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	11/30/2020

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