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General NPI Number Information
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NPI Number | 1427349687
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Entity Type | Organization
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Legal Business Name | TIMOTHY W. LOGAN, D.M.D., P.S.C.
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Dates
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Enumeration Date | 04/22/2011
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Last Update Date | 04/22/2011
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Provider Practice Location Address
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Address Line | 9800 SHELBYVILLE RD SUITE 202
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City | LOUISVILLE
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State | KY
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Zip | 40223-5440
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Country | US
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Telephone | 502-429-0526
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Fax | 502-429-0532
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Provider Business Mailing Address
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Address Line | 9800 SHELBYVILLE ROAD SUITE 202
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City | LOUISVILLE
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State | KY
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Zip | 40223-5440
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Country | US
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Telephone | 502-429-0526
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Fax | 502-429-0532
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY WILSON LOGAN
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Credential | D.M.D.
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Telephone | 502-429-0526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5015
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License Number State | KY
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