Provider Demographics
NPI:1164645438
Name:LOGAN H. CHILDERS JR. D.D.S. AND ASSOCIATES
Entity Type:Organization
Organization Name:LOGAN H. CHILDERS JR. D.D.S. AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-478-4202
Mailing Address - Street 1:12600 E US HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5955
Mailing Address - Country:US
Mailing Address - Phone:816-478-4202
Mailing Address - Fax:
Practice Address - Street 1:12600 E US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5955
Practice Address - Country:US
Practice Address - Phone:816-478-4202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO011990122300000X
MO0106481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Single Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty