Provider Demographics
NPI:1043221153
Name:LOGAN, POLLY JO COURTNEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:POLLY JO
Middle Name:COURTNEY
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DDS
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Other - Credentials:
Mailing Address - Street 1:PO BOX 291
Mailing Address - Street 2:ST CROIX VALLEY DENTAL PLLC
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-439-2600
Mailing Address - Fax:651-439-2211
Practice Address - Street 1:13961 60TH ST
Practice Address - Street 2:ST CROIX VALLEY DENTAL
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-2600
Practice Address - Fax:651-439-2211
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MND11950122300000X
WI5740015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist