Provider Demographics
NPI:1407840010
Name:SMITH, LOGAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:MICHAEL
Last Name:SMITH
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 1:5220 NEIL ROAD #200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502
Mailing Address - Country:US
Mailing Address - Phone:775-826-2826
Mailing Address - Fax:
Practice Address - Street 1:5220 NEIL RD STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6536
Practice Address - Country:US
Practice Address - Phone:775-826-2826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486801223G0001X
NV50801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1265495964OtherCOLOSIMO DENTAL GROUP NPI
NV68-0614740OtherCOLOSIMO DENTAL TIN#