Provider Demographics
NPI:1649320672
Name:LONG, KEITH M (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:M
Last Name:LONG
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 1:755 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-3705
Mailing Address - Country:US
Mailing Address - Phone:707-263-7023
Mailing Address - Fax:707-263-6963
Practice Address - Street 1:755 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-3705
Practice Address - Country:US
Practice Address - Phone:707-263-7023
Practice Address - Fax:707-263-6963
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist