Provider Demographics
NPI:1255670063
Name:JASON R LONG DDS, PLLC
Entity type:Organization
Organization Name:JASON R LONG DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:1628 WEST 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661
Mailing Address - Country:US
Mailing Address - Phone:304-236-2366
Mailing Address - Fax:304-899-2227
Practice Address - Street 1:1628 WEST 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661
Practice Address - Country:US
Practice Address - Phone:304-236-2366
Practice Address - Fax:304-899-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty