MEDICARE: DR. DENNIS R 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	1223G0001X	General Practice Dentistry	4866	KY

General Provider Information

NPI Number	:	1881792877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS R LONG DMD

Provider Business Mailing Address
First Line	:	1100 WASHINGTON STREET
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-1462
Country	:	US
Telephone Number	:	502-633-1915
Fax Number	:	502-633-1098

Provider Business Practice Location Address
First Line	:	1100 WASHINGTON STREET
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-1462
Country	:	US
Telephone Number	:	502-633-1915
Fax Number	:	502-633-1098

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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