Provider Demographics
NPI:1679222780
Name:LOGAN, CANDICE ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ELIZABETH
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28184 NEW BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3221
Mailing Address - Country:US
Mailing Address - Phone:248-787-0258
Mailing Address - Fax:
Practice Address - Street 1:11601 ROBIOUS RD STE 130B
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-5605
Practice Address - Country:US
Practice Address - Phone:804-704-8982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014178361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics