Provider Demographics
NPI:1437332160
Name:LONG, ROBERT EARL SR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EARL
Last Name:LONG
Suffix:SR
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 1:527 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-5216
Mailing Address - Country:US
Mailing Address - Phone:662-627-2565
Mailing Address - Fax:662-627-2524
Practice Address - Street 1:527 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-5216
Practice Address - Country:US
Practice Address - Phone:662-627-2565
Practice Address - Fax:662-627-2524
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS186980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064885Medicaid