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General NPI Number Information
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NPI Number | 1003509159
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Entity Type | Individual
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Provider Name | LOGAN ALEXANDER WOOD DDS
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Gender | Male
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Dates
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Enumeration Date | 06/02/2023
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Last Update Date | 06/02/2023
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Provider Practice Location Address
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Address Line | 932 SPRING ST STE 102
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City | PETOSKEY
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State | MI
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Zip | 49770-2286
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Country | US
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Telephone | 231-646-8005
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Fax |
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Provider Business Mailing Address
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Address Line | 410 W LAKE ST
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City | PETOSKEY
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State | MI
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Zip | 49770-2267
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Country | US
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Telephone | 248-622-7434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901601718
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License Number State | MI
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