Provider Demographics
NPI:1548466683
Name:LONGSTREET, CEMERON LAVAR (DDS)
Entity type:Individual
Prefix:DR
First Name:CEMERON
Middle Name:LAVAR
Last Name:LONGSTREET
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HALTON RD APT 8102
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3466
Mailing Address - Country:US
Mailing Address - Phone:864-234-7461
Mailing Address - Fax:
Practice Address - Street 1:3903 AUGUSTA RD
Practice Address - Street 2:PIEDMONT DENTAL CENTER
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-1337
Practice Address - Country:US
Practice Address - Phone:864-299-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist