Provider Demographics
NPI:1104802701
Name:LONG, EDWIN U (DDS)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:U
Last Name:LONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 E PEARL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701
Mailing Address - Country:US
Mailing Address - Phone:816-380-4029
Mailing Address - Fax:816-380-6522
Practice Address - Street 1:202 S LEXINGTON
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-5317
Practice Address - Country:US
Practice Address - Phone:816-380-3522
Practice Address - Fax:816-380-6522
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist