Provider Demographics
NPI:1588891568
Name:LONG, ROBERT ANTHONY (DMD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ANTHONY
Last Name:LONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:MR
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1512 PIEDMONT AVE NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5044
Mailing Address - Country:US
Mailing Address - Phone:404-873-2957
Mailing Address - Fax:404-873-2526
Practice Address - Street 1:1512 PIEDMONT AVE NE
Practice Address - Street 2:SUITE 202
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5044
Practice Address - Country:US
Practice Address - Phone:404-873-2957
Practice Address - Fax:404-873-2526
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011873122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist