Organization
TIMOTHY W. LOGAN, D.M.D., P.S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TIMOTHY WILSON LOGAN D.M.D. (OWNER)
(502) 429-0526
Entity
Organization
Contact information
Practice address
9800 SHELBYVILLE RD, SUITE 202, LOUISVILLE, KY 40223-5440
(502) 429-0526
(502) 429-0532
Mailing address
9800 SHELBYVILLE ROAD, SUITE 202, LOUISVILLE, KY 40223-5440
(502) 429-0526
(502) 429-0532
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
5015
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000049874
BLUE CROSS/BLUE SHIEL
—
01
—
1548227655
NPI TYPE 1
—
Enumeration date
04/22/2011
Last updated
04/22/2011
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