Provider Demographics
NPI:1861409716
Name:LOGAN, MATTHEW L (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:LOGAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 WAMPLERS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9585
Mailing Address - Country:US
Mailing Address - Phone:517-592-3857
Mailing Address - Fax:517-592-5787
Practice Address - Street 1:170 WAMPLERS LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9585
Practice Address - Country:US
Practice Address - Phone:517-592-3857
Practice Address - Fax:517-592-5787
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014195122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist