Provider Demographics
NPI:1427079359
Name:LOGANATHAN, GANESH (DENTIST)
Entity type:Individual
Prefix:MR
First Name:GANESH
Middle Name:
Last Name:LOGANATHAN
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 S DIXIE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45409
Mailing Address - Country:US
Mailing Address - Phone:937-298-4221
Mailing Address - Fax:937-395-3665
Practice Address - Street 1:3020 S DIXIE DRIVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-298-4221
Practice Address - Fax:937-395-3665
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30019355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0909511Medicaid