Healthcare Provider Details

I. General information

NPI: 1700851524
Provider Name (Legal Business Name): LOGAN H. CHILDERS JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 E 40 HWY
INDEPENDENCE MO
64055-5955
US

IV. Provider business mailing address

12600 E 40 HWY
INDEPENDENCE MO
64055-5955
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-4202
  • Fax: 816-478-8920
Mailing address:
  • Phone: 816-478-4202
  • Fax: 816-478-8920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number010648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: