Healthcare Provider Details

I. General information

NPI: 1588986525
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3162 STATE ST
MEDFORD OR
97504-8450
US

IV. Provider business mailing address

3162 STATE ST
MEDFORD OR
97504-8450
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-7799
  • Fax: 541-779-7805
Mailing address:
  • Phone: 541-779-7799
  • Fax: 541-779-7805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: BRUCE S LOGAN
Title or Position: OWNER
Credential: DDS
Phone: 541-779-7799