Provider Demographics
NPI:1912161464
Name:LOGAN, WADE (DDS)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
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 1:8701 CAMINO MEDIA
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-1335
Mailing Address - Country:US
Mailing Address - Phone:661-861-8000
Mailing Address - Fax:661-616-5464
Practice Address - Street 1:8701 CAMINO MEDIA
Practice Address - Street 2:SUITE A
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-1335
Practice Address - Country:US
Practice Address - Phone:661-861-8000
Practice Address - Fax:661-616-5464
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA447331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice