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General NPI Number Information
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NPI Number | 1740577592
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Entity Type | Individual
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Provider Name | LOGAN COLLINS BANNER D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 07/28/2024
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Provider Practice Location Address
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Address Line | 2120 BERT KOUNS INDUSTRIAL LOOP STE D
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City | SHREVEPORT
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State | LA
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Zip | 71118-3351
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Country | US
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Telephone | 318-687-9800
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Fax |
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Provider Business Mailing Address
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Address Line | 5718 MARINA BAY DR
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City | SHREVEPORT
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State | LA
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Zip | 71119-3918
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Country | US
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Telephone | 206-718-3063
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DE60226297
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 32707
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 7046
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License Number State | LA
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