Healthcare Provider Details

I. General information

NPI: 1922840305
Provider Name (Legal Business Name): KAITLYN AMINAH BROOKE LOGAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 E OCEAN AVE
LOMPOC CA
93436-7014
US

IV. Provider business mailing address

1015 HENRY AVE APT J
SANTA MARIA CA
93455-8401
US

V. Phone/Fax

Practice location:
  • Phone: 614-581-5191
  • Fax:
Mailing address:
  • Phone: 614-581-5191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number111976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: