Provider Demographics
NPI:1558467803
Name:BINGHAM, LEGRAND (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEGRAND
Middle Name:
Last Name:BINGHAM
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 1:120 W CACHE VALLEY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-753-7563
Mailing Address - Fax:435-753-0886
Practice Address - Street 1:120 W CACHE VALLEY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-753-7563
Practice Address - Fax:435-753-0886
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1410291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice