Provider Demographics
NPI:1174258503
Name:HARMON, LOGAN MATTHEW
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:MATTHEW
Last Name:HARMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 HOFF ST
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-5645
Mailing Address - Country:US
Mailing Address - Phone:706-544-2051
Mailing Address - Fax:
Practice Address - Street 1:7101 HOFF ST
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5645
Practice Address - Country:US
Practice Address - Phone:706-544-2051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205210122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist