Provider Demographics
NPI:1255179636
Name:SOPHIE LOGAN DDS MMSC PC
Entity type:Organization
Organization Name:SOPHIE LOGAN DDS MMSC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MMSC
Authorized Official - Phone:831-531-7660
Mailing Address - Street 1:115 SEGRE PL
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3160
Mailing Address - Country:US
Mailing Address - Phone:831-331-1903
Mailing Address - Fax:
Practice Address - Street 1:824 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3681
Practice Address - Country:US
Practice Address - Phone:707-849-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental