Provider Demographics
NPI:1366021040
Name:RUTCH, LOGAN DAVIS (DMD, MMS)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:DAVIS
Last Name:RUTCH
Suffix:
Gender:M
Credentials:DMD, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 WALNUT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3602
Mailing Address - Country:US
Mailing Address - Phone:570-999-6695
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST STE 200
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3602
Practice Address - Country:US
Practice Address - Phone:215-999-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS043311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program