=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164645438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOGAN H. CHILDERS JR. D.D.S. AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12600 E US HIGHWAY 40
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64055-5955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-4202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12600 E US HIGHWAY 40
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64055-5955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-478-4202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LOGAN H CHILDERS JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 816-478-4202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 010648
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 011990
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------