Provider Demographics
NPI:1174016661
Name:WHEELER, LOGAN
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CAPEHART RD
Mailing Address - Street 2:
Mailing Address - City:OFFUTT AFB
Mailing Address - State:NE
Mailing Address - Zip Code:68113-1043
Mailing Address - Country:US
Mailing Address - Phone:765-748-9073
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113
Practice Address - Country:US
Practice Address - Phone:765-748-9073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012942A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice