Healthcare Provider Details

I. General information

NPI: 1861409716
Provider Name (Legal Business Name): MATTHEW L. LOGAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 WAMPLERS LAKE RD
BROOKLYN MI
49230-9585
US

IV. Provider business mailing address

170 WAMPLERS LAKE RD
BROOKLYN MI
49230-9585
US

V. Phone/Fax

Practice location:
  • Phone: 517-592-3857
  • Fax: 517-592-5787
Mailing address:
  • Phone: 517-592-3857
  • Fax: 517-592-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901014195
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901014195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: