Provider Demographics
NPI:1962924407
Name:KING, LOGAN DONALD (DMD)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:DONALD
Last Name:KING
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RIVER ST APT 237
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3088
Mailing Address - Country:US
Mailing Address - Phone:603-290-2195
Mailing Address - Fax:
Practice Address - Street 1:668 FAIRVIEW RD # B
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6708
Practice Address - Country:US
Practice Address - Phone:864-626-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC89771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice