Provider Demographics
NPI:1821168071
Name:LOGAN, JIM WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:WESLEY
Last Name:LOGAN
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 1:519 E FRANKLIN
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-5337
Mailing Address - Country:US
Mailing Address - Phone:580-772-1612
Mailing Address - Fax:580-772-0062
Practice Address - Street 1:519 E FRANKLIN
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-5337
Practice Address - Country:US
Practice Address - Phone:580-772-1612
Practice Address - Fax:580-772-0062
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK33191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice