Provider Demographics
NPI:1548227655
Name:LOGAN, TIMOTHY W (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:LOGAN
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 1:9800 SHELBYVILLE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2977
Mailing Address - Country:US
Mailing Address - Phone:502-429-0526
Mailing Address - Fax:502-429-0532
Practice Address - Street 1:9800 SHELBYVILLE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2977
Practice Address - Country:US
Practice Address - Phone:502-429-0526
Practice Address - Fax:502-429-0532
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50151223S0112X
IN12010128A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000049874OtherBLUE CROSS BLUE SHIELD
17801601Medicare ID - Type Unspecified
000000049874OtherBLUE CROSS BLUE SHIELD