Provider Demographics
NPI:1104355395
Name:LONGSHORE, DORIAN GRACE (DMD)
Entity type:Individual
Prefix:
First Name:DORIAN
Middle Name:GRACE
Last Name:LONGSHORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 HOLMES DR SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4726
Mailing Address - Country:US
Mailing Address - Phone:470-255-4855
Mailing Address - Fax:
Practice Address - Street 1:4799 ATLANTA HWY # 500
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7307
Practice Address - Country:US
Practice Address - Phone:404-609-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0154301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice