MEDICARE: DR. LOGAN CHARLES MCINTIRE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN123081	GA

General Provider Information

NPI Number	:	1932886181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOGAN CHARLES MCINTIRE DMD

Provider Business Mailing Address
First Line	:	3237 SIXES RD
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-7965
Country	:	US
Telephone Number	:	678-880-9775
Fax Number	:

Provider Business Practice Location Address
First Line	:	3237 SIXES RD
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-7965
Country	:	US
Telephone Number	:	678-880-9775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2023
Last Update Date	:	06/29/2023

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