Provider Demographics
NPI:1689026205
Name:LOCKE, LOGAN (DDS)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:LOCKE
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 1:6321 S REDWOOD RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6798
Mailing Address - Country:US
Mailing Address - Phone:801-590-8694
Mailing Address - Fax:
Practice Address - Street 1:6321 S REDWOOD RD
Practice Address - Street 2:SUITE 206
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6798
Practice Address - Country:US
Practice Address - Phone:801-590-8694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9795445-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice