Provider Demographics
NPI:1427349687
Name:TIMOTHY W. LOGAN, D.M.D., P.S.C.
Entity type:Organization
Organization Name:TIMOTHY W. LOGAN, D.M.D., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-429-0526
Mailing Address - Street 1:9800 SHELBYVILLE ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5440
Mailing Address - Country:US
Mailing Address - Phone:502-429-0526
Mailing Address - Fax:502-429-0532
Practice Address - Street 1:9800 SHELBYVILLE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5440
Practice Address - Country:US
Practice Address - Phone:502-429-0526
Practice Address - Fax:502-429-0532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1548227655OtherNPI TYPE 1
000000049874OtherBLUE CROSS/BLUE SHIEL
17801601Medicare PIN
1548227655OtherNPI TYPE 1