Provider Demographics
NPI:1588877500
Name:LONG, ROBERT MICHAEL
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
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 1:4359 KUKUI GROVE ST
Mailing Address - Street 2:#104
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2008
Mailing Address - Country:US
Mailing Address - Phone:808-245-3722
Mailing Address - Fax:
Practice Address - Street 1:4359 KUKUI GROVE ST
Practice Address - Street 2:#104
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2008
Practice Address - Country:US
Practice Address - Phone:808-245-3722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT 9391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice