Provider Demographics
NPI:1386058253
Name:LONGO, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:LONGO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2808
Mailing Address - Country:US
Mailing Address - Phone:917-992-2646
Mailing Address - Fax:919-910-5532
Practice Address - Street 1:814 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2808
Practice Address - Country:US
Practice Address - Phone:919-714-2928
Practice Address - Fax:919-910-5532
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10180122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist