Provider Demographics
NPI:1427365204
Name:MICHAEL P. LOGUE, D.M.D., P.A.
Entity Type:Organization
Organization Name:MICHAEL P. LOGUE, D.M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-941-2727
Mailing Address - Street 1:1800 N FEDERAL HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-1034
Mailing Address - Country:US
Mailing Address - Phone:954-941-2727
Mailing Address - Fax:954-941-1116
Practice Address - Street 1:1800 N FEDERAL HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-1034
Practice Address - Country:US
Practice Address - Phone:954-941-2727
Practice Address - Fax:954-941-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12346261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071462300Medicaid
FLU25198Medicare UPIN
FL69032Medicare PIN