Healthcare Provider Details

I. General information

NPI: 1043053796
Provider Name (Legal Business Name): LOGAN KEITH CONNOR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-2521
US

IV. Provider business mailing address

7051 DA MAR EST
SAINT PETER MN
56082-9431
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-8669
  • Fax:
Mailing address:
  • Phone: 507-995-0326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD15116
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: