Provider Demographics
NPI:1154814317
Name:LOGHMANIAN, AUTRINE (DMD)
Entity Type:Individual
Prefix:
First Name:AUTRINE
Middle Name:
Last Name:LOGHMANIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CHIHUAHUA TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-2352
Mailing Address - Country:US
Mailing Address - Phone:703-507-3457
Mailing Address - Fax:
Practice Address - Street 1:4410 E RIVERSIDE DR STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741
Practice Address - Country:US
Practice Address - Phone:512-669-5049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice