Provider Demographics
NPI:1982088407
Name:PHUNG, LONG K (DMD)
Entity type:Individual
Prefix:
First Name:LONG
Middle Name:K
Last Name:PHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 DULUTH HWY STE E2
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5399
Mailing Address - Country:US
Mailing Address - Phone:678-209-2273
Mailing Address - Fax:
Practice Address - Street 1:911 DULUTH HWY STE E2
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5399
Practice Address - Country:US
Practice Address - Phone:678-209-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016140122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist