Provider Demographics
NPI:1497319719
Name:GOULET, LOGAN PAUL (DMD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:PAUL
Last Name:GOULET
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 1:342 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9340
Mailing Address - Country:US
Mailing Address - Phone:509-671-2617
Mailing Address - Fax:
Practice Address - Street 1:3150 E 27TH AVE # 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4919
Practice Address - Country:US
Practice Address - Phone:509-838-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE609655391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice