Provider Demographics
NPI:1447138169
Name:THORNTON, LOGAN MICHELLE (RDH, PHDH)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MICHELLE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:RDH, PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4644
Mailing Address - Country:US
Mailing Address - Phone:217-235-0800
Mailing Address - Fax:217-235-0801
Practice Address - Street 1:225 RICHMOND AVE E STE B
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4651
Practice Address - Country:US
Practice Address - Phone:217-235-0800
Practice Address - Fax:217-235-0801
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.013221124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist