Basic Information
| Provider Information | |||||||||
| NPI: | 1073707519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGIE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | DWIGHT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268819 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695569398 | ||||||||
| FaxNumber: | 2695569488 | ||||||||
| Practice Location | |||||||||
| Address1: | 2776 RINGGOLD ROAD | ||||||||
| Address2: | ATTN: CREDENTIALS COORDINATOR | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735036300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | 5804424002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | L117008 | MI | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.