Provider Demographics
NPI:1104121375
Name:LONG, REBECCA L (DDS)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S CAPITAL OF TEXAS HWY STE 132A
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7012
Mailing Address - Country:US
Mailing Address - Phone:512-328-0155
Mailing Address - Fax:512-327-8420
Practice Address - Street 1:1301 S CAPITAL OF TEXAS HWY STE 132A
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-7012
Practice Address - Country:US
Practice Address - Phone:512-328-0155
Practice Address - Fax:512-327-8420
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028027122300000X
TX366821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist