Provider Demographics
NPI:1801015375
Name:LOGULLO, JON LAURENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:LAURENCE
Last Name:LOGULLO
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:P. O. BOX 398
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-6224
Mailing Address - Country:US
Mailing Address - Phone:618-664-2236
Mailing Address - Fax:618-664-0386
Practice Address - Street 1:411 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1020
Practice Address - Country:US
Practice Address - Phone:618-664-2236
Practice Address - Fax:618-664-0386
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice