Provider Demographics
NPI:1790521409
Name:LOUQUE, LOGAN (DDS)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:
Last Name:LOUQUE
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 1:2211 TRADE ST
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-7683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 CHAPIN RD STE A
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-7142
Practice Address - Country:US
Practice Address - Phone:803-994-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.10861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty