Provider Demographics
NPI:1154549087
Name:LOGAN, BRUCE ALAN (DDS, MAGD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DDS, MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22910 CRENSHAW BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3060
Mailing Address - Country:US
Mailing Address - Phone:310-534-1809
Mailing Address - Fax:310-539-1079
Practice Address - Street 1:22910 CRENSHAW BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3060
Practice Address - Country:US
Practice Address - Phone:310-534-1809
Practice Address - Fax:310-539-1079
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice