Provider Demographics
NPI:1154536563
Name:LONG, ERIKA KAY (DDS)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:KAY
Last Name:LONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ERIKA
Other - Middle Name:KAY
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1600 S 4TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-3401
Mailing Address - Country:US
Mailing Address - Phone:309-263-2781
Mailing Address - Fax:309-263-4161
Practice Address - Street 1:1600 S 4TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-3401
Practice Address - Country:US
Practice Address - Phone:309-263-2781
Practice Address - Fax:309-263-4161
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist