Provider Demographics
NPI:1073707519
Name:LOGIE, BRADLEY DWIGHT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DWIGHT
Last Name:LOGIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268819
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8819
Mailing Address - Country:US
Mailing Address - Phone:269-556-9398
Mailing Address - Fax:269-556-9488
Practice Address - Street 1:2776 RINGGOLD ROAD
Practice Address - Street 2:ATTN: CREDENTIALS COORDINATOR
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:580-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1170081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery