Provider Demographics
NPI:1003509159
Name:WOOD, LOGAN ALEXANDER (DDS)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:ALEXANDER
Last Name:WOOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2267
Mailing Address - Country:US
Mailing Address - Phone:248-622-7434
Mailing Address - Fax:
Practice Address - Street 1:932 SPRING ST STE 102
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2286
Practice Address - Country:US
Practice Address - Phone:231-646-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016017181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty