MEDICARE: MR. C. ROSS LONG DDS

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	122300000X	Dentist	2057	NM

General Provider Information

NPI Number	:	1306865647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. C. ROSS LONG DDS

Provider Business Mailing Address
First Line	:	3740 COORS BLVD NW STE A
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4762
Country	:	US
Telephone Number	:	505-836-1280
Fax Number	:	505-839-4782

Provider Business Practice Location Address
First Line	:	3740 COORS BLVD NW STE A
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4762
Country	:	US
Telephone Number	:	505-836-1280
Fax Number	:	505-839-4782

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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