Provider Demographics
NPI:1588986525
Name:ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-779-7799
Mailing Address - Street 1:3162 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-779-7799
Mailing Address - Fax:541-779-7805
Practice Address - Street 1:3162 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-779-7799
Practice Address - Fax:541-779-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty