Provider Demographics
NPI:1144603812
Name:LOGAN, SHAUN (DMD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:LOGAN
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 1:621 DAYTON STREET
Mailing Address - Street 2:
Mailing Address - City:RANCHESTER
Mailing Address - State:WY
Mailing Address - Zip Code:82839
Mailing Address - Country:US
Mailing Address - Phone:307-655-9810
Mailing Address - Fax:
Practice Address - Street 1:621 DAYTON STREET
Practice Address - Street 2:
Practice Address - City:RANCHESTER
Practice Address - State:WY
Practice Address - Zip Code:82839
Practice Address - Country:US
Practice Address - Phone:307-655-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice