=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821401068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOGAN CONRAD SMITH DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2014
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7706 GEORGETOWN CENTER DR STE A
-----------------------------------------------------
City | JENISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49428-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-855-0005
-----------------------------------------------------
Fax | 616-855-0048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7706 GEORGETOWN CENTER DR STE A
-----------------------------------------------------
City | JENISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49428-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-855-0005
-----------------------------------------------------
Fax | 616-855-0048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901021197
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------