Provider Demographics
NPI:1417486192
Name:HALL, LOGAN BRODY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:BRODY
Last Name:HALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 N OKLAHOMA WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-4445
Mailing Address - Country:US
Mailing Address - Phone:479-461-1804
Mailing Address - Fax:
Practice Address - Street 1:712 W MEADOW AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4462
Practice Address - Country:US
Practice Address - Phone:479-751-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR41771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice