Basic Information
Provider Information
NPI: 1568905099
EntityType: 2
ReplacementNPI:  
OrganizationName: LOGAN NALLEY III, D.M.D., P.C.
LastName:  
FirstName:  
MiddleName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: PO BOX 3189
Address2:  
City: SYRACUSE
State: NY
PostalCode: 132203189
CountryCode: US
TelephoneNumber: 3154546000
FaxNumber: 3154105531
Practice Location
Address1: 1961 WHISKEY RD
Address2:  
City: AIKEN
State: SC
PostalCode: 298037603
CountryCode: US
TelephoneNumber: 8037168434
FaxNumber: 8036489183
Other Information
ProviderEnumerationDate: 12/01/2016
LastUpdateDate: 12/01/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: NALLEY
AuthorizedOfficialFirstName: LOGAN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: DMD/OWNER
AuthorizedOfficialTelephone: 8037168434
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix: III
AuthorizedOfficialCredential: DR
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X8190SCY193400000X SINGLE SPECIALTY GROUPDental ProvidersDentistGeneral Practice

No ID Information.


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