Provider Demographics
NPI:1760426803
Name:LOGAN, MARK P (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:LOGAN
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 1:123 DWIGHT RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1748
Mailing Address - Country:US
Mailing Address - Phone:413-567-0341
Mailing Address - Fax:413-567-7299
Practice Address - Street 1:123 DWIGHT RD
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1748
Practice Address - Country:US
Practice Address - Phone:413-567-0341
Practice Address - Fax:413-567-7299
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics