Healthcare Provider Details

I. General information

NPI: 1356076624
Provider Name (Legal Business Name): LOGAN SAMUEL MORRIS DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 W ILES AVE STE C
SPRINGFIELD IL
62704-4194
US

IV. Provider business mailing address

2050 W ILES AVE STE C
SPRINGFIELD IL
62704-4194
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-6150
  • Fax: 217-698-6151
Mailing address:
  • Phone: 217-698-6150
  • Fax: 217-698-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021.003554
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: