Provider Demographics
NPI:1760062061
Name:WILSON, LOGAN (DMD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 WESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:LANESBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01237-9516
Mailing Address - Country:US
Mailing Address - Phone:413-841-2094
Mailing Address - Fax:
Practice Address - Street 1:77 ELM ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6503
Practice Address - Country:US
Practice Address - Phone:413-442-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18596781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty