Provider Demographics
NPI:1598024341
Name:LOGAN ORAL SURGERY
Entity Type:Organization
Organization Name:LOGAN ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-754-7130
Mailing Address - Street 1:3125 N. MAIN STREET
Mailing Address - Street 2:STE #103
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1550
Mailing Address - Country:US
Mailing Address - Phone:435-754-7130
Mailing Address - Fax:435-535-2464
Practice Address - Street 1:3125 N. MAIN STREET
Practice Address - Street 2:STE #103
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1550
Practice Address - Country:US
Practice Address - Phone:435-754-7130
Practice Address - Fax:435-535-2464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8227102-9924261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery