MEDICARE: KIMBERLY NICOLE LONG DENTAL HYGIENIST

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	DH011822	GA

General Provider Information

NPI Number	:	1649055104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY NICOLE LONG DENTAL HYGIENIST

Provider Business Mailing Address
First Line	:	829 WHITE ST SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-2721
Country	:	US
Telephone Number	:	626-243-3484
Fax Number	:

Provider Business Practice Location Address
First Line	:	2578 GRESHAM RD SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-4138
Country	:	US
Telephone Number	:	404-688-1350
Fax Number	:

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

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	08/31/2023

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