Provider Demographics
NPI:1275871717
Name:LIFE LONG DENTAL CARE
Entity type:Organization
Organization Name:LIFE LONG DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-388-0242
Mailing Address - Street 1:123 ELM ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4108
Mailing Address - Country:US
Mailing Address - Phone:860-388-0242
Mailing Address - Fax:860-388-6495
Practice Address - Street 1:123 ELM ST
Practice Address - Street 2:SUITE 900
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4108
Practice Address - Country:US
Practice Address - Phone:860-388-0242
Practice Address - Fax:860-388-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT079441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty