MEDICARE: MARKISHA LONG RDH

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	124Q00000X	Dental Hygienist	2902016124	MI
2	124Q00000X	Dental Hygienist	H007204	AZ
3	124Q00000X	Dental Hygienist	DH011158	GA

General Provider Information

NPI Number	:	1326490624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARKISHA LONG RDH

Provider Business Mailing Address
First Line	:	3718 GRUBER RD
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-8934
Country	:	US
Telephone Number	:	910-396-1571
Fax Number	:

Provider Business Practice Location Address
First Line	:	3718 GRUBER RD
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-8934
Country	:	US
Telephone Number	:	910-396-1571
Fax Number	:

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

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	07/11/2016

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