Provider Demographics
NPI:1245231778
Name:LOGAN, THEODORE E JR (DMD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:E
Last Name:LOGAN
Suffix:JR
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 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:STE 2D
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-459-8012
Mailing Address - Fax:502-459-8021
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:STE 2D
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-459-8012
Practice Address - Fax:502-459-8021
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64040561Medicaid
KY1055007OtherPASSPORT
KY60040565OtherMEDICAID DENTAL
KY60040565OtherMEDICAID DENTAL
U09220Medicare UPIN