MEDICARE: DR. LOGAN T CLEMENTS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	290102246	MI

General Provider Information

NPI Number	:	1942730700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOGAN T CLEMENTS DDS

Provider Business Mailing Address
First Line	:	4860 FIELDSTONE LN APT 9
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-8997
Country	:	US
Telephone Number	:	810-955-9711
Fax Number	:

Provider Business Practice Location Address
First Line	:	1936 S SUMMERTON RD
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-1109
Country	:	US
Telephone Number	:	989-773-9051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/14/2017

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