Healthcare Provider Details

I. General information

NPI: 1710803986
Provider Name (Legal Business Name): LOGAN MICHAEL SEVERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CAMPUS LOOP S
LINCOLN NE
68583-1530
US

IV. Provider business mailing address

2782 CREEKWOOD DR
CANTONMENT FL
32533-7505
US

V. Phone/Fax

Practice location:
  • Phone: 850-288-2872
  • Fax:
Mailing address:
  • Phone: 850-288-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN31737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: