Provider Demographics
NPI:1386129229
Name:LONG, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 CITY CENTER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-8953
Mailing Address - Country:US
Mailing Address - Phone:252-331-2304
Mailing Address - Fax:888-975-6590
Practice Address - Street 1:1745 CITY CENTER BLVD STE A
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8953
Practice Address - Country:US
Practice Address - Phone:252-331-2304
Practice Address - Fax:888-975-6590
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC111991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice