Provider Demographics
NPI:1790903011
Name:LOGUE, DON (DDS)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:
Last Name:LOGUE
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 1:1702 PARK HILL RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5600
Mailing Address - Country:US
Mailing Address - Phone:918-456-3082
Mailing Address - Fax:918-456-3536
Practice Address - Street 1:1702 PARK HILL RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5600
Practice Address - Country:US
Practice Address - Phone:918-456-3082
Practice Address - Fax:918-456-3536
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091210AMedicaid