Healthcare Provider Details

I. General information

NPI: 1164645438
Provider Name (Legal Business Name): LOGAN H. CHILDERS JR. D.D.S. AND ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 E US HIGHWAY 40
INDEPENDENCE MO
64055-5955
US

IV. Provider business mailing address

12600 E US HIGHWAY 40
INDEPENDENCE MO
64055-5955
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-4202
  • Fax:
Mailing address:
  • Phone: 816-478-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010648
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number011990
License Number StateMO

VIII. Authorized Official

Name: DR. LOGAN H CHILDERS JR.
Title or Position: OWNER
Credential: DDS
Phone: 816-478-4202