Provider Demographics
NPI:1124112107
Name:LONG, GENE FREDRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:GENE
Middle Name:FREDRICK
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 1:11066 5TH AVE NE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6156
Mailing Address - Country:US
Mailing Address - Phone:206-361-9869
Mailing Address - Fax:206-361-1156
Practice Address - Street 1:11066 5TH AVE NE
Practice Address - Street 2:SUITE 203
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-6156
Practice Address - Country:US
Practice Address - Phone:206-361-9869
Practice Address - Fax:206-361-1156
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000045141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice