MEDICARE: MR. ROBERT ANTHONY LONG DMD

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	DN011873	GA

General Provider Information

NPI Number	:	1588891568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT ANTHONY LONG DMD

Provider Business Mailing Address
First Line	:	1512 PIEDMONT AVE NE
Second Line	:	SUITE 202
City	:	ATLANTA
State	:	GA
Zip	:	30324-5044
Country	:	US
Telephone Number	:	404-873-2957
Fax Number	:	404-873-2526

Provider Business Practice Location Address
First Line	:	1512 PIEDMONT AVE NE
Second Line	:	SUITE 202
City	:	ATLANTA
State	:	GA
Zip	:	30324-5044
Country	:	US
Telephone Number	:	404-873-2957
Fax Number	:	404-873-2526

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

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	06/17/2009

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