Individual
THEODORE E LOGAN JR.
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
3101 BRECKENRIDGE LN, STE 2D, LOUISVILLE, KY 40220-2742
(502) 459-8012
(502) 459-8021
Mailing address
3101 BRECKENRIDGE LN, STE 2D, LOUISVILLE, KY 40220-2742
(502) 459-8012
(502) 459-8021
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
4056
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1055007
PASSPORT
KY
01
—
60040565
MEDICAID DENTAL
KY
05
—
64040561
—
KY
Enumeration date
08/09/2005
Last updated
07/08/2007
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