Provider Demographics
NPI:1740577592
Name:BANNER, LOGAN COLLINS (DDS)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:COLLINS
Last Name:BANNER
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 1:5718 MARINA BAY DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3918
Mailing Address - Country:US
Mailing Address - Phone:206-718-3063
Mailing Address - Fax:
Practice Address - Street 1:2120 BERT KOUNS INDUSTRIAL LOOP STE D
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3351
Practice Address - Country:US
Practice Address - Phone:318-687-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60226297122300000X
TX327071223S0112X
LA70461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist