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NPI Code Detail

MEDICARE: DR. TIMOTHY JOHN LONGO DDS

MEDICARE: DR. TIMOTHY JOHN LONGO 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
1122300000XDentist019.031249IL

General Provider Information

NPI Number : 1760904171
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TIMOTHY JOHN LONGO DDS
Provider Business Mailing Address
First Line : 350 N CLARK STREET STE 600
Second Line : C/O KOS SERVICES, ATTN: HR
City : CHICAGO
State : IL
Zip : 60654-4782
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4039 W NORTH AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-5219
Country : US
Telephone Number : 773-782-4800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2017
Last Update Date : 07/07/2017

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