Provider Demographics
NPI:1568819969
Name:GOAD, MICHAEL LOGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOGAN
Last Name:GOAD
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 1:5945 CRAWFORDSVILLE RD STE J
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3721
Mailing Address - Country:US
Mailing Address - Phone:317-762-3502
Mailing Address - Fax:
Practice Address - Street 1:5945 CRAWFORDSVILLE RD STE J
Practice Address - Street 2:
Practice Address - City:SPEEDWAY
Practice Address - State:IN
Practice Address - Zip Code:46224-3721
Practice Address - Country:US
Practice Address - Phone:317-762-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012469A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist