Provider Demographics
NPI:1841210572
Name:LOGELIN, MICHAEL GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:LOGELIN
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 1:3757 CAMINO BELLA ROSA
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9410
Mailing Address - Country:US
Mailing Address - Phone:702-326-8519
Mailing Address - Fax:520-378-9982
Practice Address - Street 1:BLDG 45005 RUNION DENTAL CLINIC
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85670
Practice Address - Country:US
Practice Address - Phone:520-533-3144
Practice Address - Fax:520-533-7285
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283531223G0001X
NV34811223G0001X
CO98581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32170513Medicaid
CAD28353Medicaid
NV002202771Medicaid