Healthcare Provider Details

I. General information

NPI: 1235261272
Provider Name (Legal Business Name): LOGAN NALLEY JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3643 WALTON WAY EXT
AUGUSTA GA
30909-4507
US

IV. Provider business mailing address

3643 WALTON WAY EXT
AUGUSTA GA
30909-4507
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-8641
  • Fax: 706-733-8615
Mailing address:
  • Phone: 706-733-8641
  • Fax: 706-733-8615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number8956
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2237
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: