Provider Demographics
NPI:1225654882
Name:GOODRICH, LOGAN CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:CHARLES
Last Name:GOODRICH
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 1:8429 HUNTERS KNOLL RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-6406
Mailing Address - Country:US
Mailing Address - Phone:260-515-8864
Mailing Address - Fax:
Practice Address - Street 1:1234 E DUPONT RD STE 4
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-490-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013386A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist