Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0700X | Prosthodontist | 2237 | SC |
Y | 1223P0700X | Prosthodontist | 8956 | GA |
NPI | 1235261272 |
---|---|
Provider Name | Dr. Logan Nalley JR. |
First Address | Augusta, GA 30909-4507 |
Second Address | Augusta, GA 30909-4507 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2007 |
Last Update Date | 08/07/2007 |