Healthcare Provider Details

I. General information

NPI: 1487705166
Provider Name (Legal Business Name): DEAN M LOGUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 TRIMMIER RD SUITE 170
KILLEEN TX
76542-1908
US

IV. Provider business mailing address

105 N AUSTIN AVE APT 6103
GEORGETOWN TX
78626-4244
US

V. Phone/Fax

Practice location:
  • Phone: 254-501-3234
  • Fax:
Mailing address:
  • Phone: 979-285-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13991
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: