Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 7687 | MN |
NPI | 1003908971 |
---|---|
Provider Name | Dr. Michael David Long |
First Address | Sauk Centre, MN 56378-0187 |
Second Address | Sauk Centre, MN 56378-0187 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2006 |
Last Update Date | 08/07/2007 |