WALLACE DALE LONG Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****72

License Status

NOT RENEWED

Business

First Name

WALLACE DALE

Last Name

LONG

Business Name

WALLACE DALE LONG

Original Issue Date

01/01/1998

Expiration Date

09/30/1994

City

DECATUR

State

Zip

62523

County

MACON

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/13/2005