Provider Demographics
NPI:1043053796
Name:CONNOR, LOGAN KEITH (DMD)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:KEITH
Last Name:CONNOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 DA MAR EST
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-9431
Mailing Address - Country:US
Mailing Address - Phone:507-995-0326
Mailing Address - Fax:
Practice Address - Street 1:5831 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2521
Practice Address - Country:US
Practice Address - Phone:763-533-8669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND151161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice