Healthcare Provider Details

I. General information

NPI: 1841184199
Provider Name (Legal Business Name): LOGAN AUTRY CUMBAA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 VINE ST NE
GAINESVILLE GA
30501-2535
US

IV. Provider business mailing address

248 DUE SOUTH RD
WHIGHAM GA
39897-4032
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-4555
  • Fax:
Mailing address:
  • Phone: 229-289-7229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123787
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: