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General NPI Number Information
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NPI Number | 1235261272
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Entity Type | Individual
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Provider Name | LOGAN NALLEY JR. D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3643 WALTON WAY EXT
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City | AUGUSTA
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State | GA
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Zip | 30909-4507
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Country | US
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Telephone | 706-733-8641
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Fax | 706-733-8615
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Provider Business Mailing Address
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Address Line | 3643 WALTON WAY EXT
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City | AUGUSTA
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State | GA
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Zip | 30909-4507
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Country | US
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Telephone | 706-733-8641
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Fax | 706-733-8615
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 8956
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 2237
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License Number State | SC
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