=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568008407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIE ELIZABETH LOGAN DDS, MMSC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2019
-----------------------------------------------------
Last Update Date | 02/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 MISSION ST
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-3681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-331-1903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 TORREY PINE TER
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-331-1903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 106072
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------