Provider Demographics
NPI:1962825117
Name:TIFFANI A. LONG DDS
Entity type:Organization
Organization Name:TIFFANI A. LONG DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-842-7788
Mailing Address - Street 1:1115 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3819
Mailing Address - Country:US
Mailing Address - Phone:503-842-7788
Mailing Address - Fax:
Practice Address - Street 1:1115 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3819
Practice Address - Country:US
Practice Address - Phone:503-842-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10033261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty