Healthcare Provider Details

I. General information

NPI: 1841210572
Provider Name (Legal Business Name): MICHAEL GREGORY LOGELIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 45005 RUNION DENTAL CLINIC USA DENTAC
FT HUACHUCA AZ
85670
US

IV. Provider business mailing address

3757 CAMINO BELLA ROSA
SIERRA VISTA AZ
85650-9410
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-3144
  • Fax: 520-533-7285
Mailing address:
  • Phone: 702-326-8519
  • Fax: 520-378-9982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28353
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3481
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9858
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: