Provider Demographics
NPI:1922450212
Name:WHITE, LOGAN (DDS)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WHITE
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 1:2215 FULLER ROAD
Mailing Address - Street 2:VAMC DENTAL SERVICE (160)
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9923
Mailing Address - Country:US
Mailing Address - Phone:734-845-3528
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER ROAD
Practice Address - Street 2:VAMC DENTAL SERVICE (160)
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9923
Practice Address - Country:US
Practice Address - Phone:734-845-3528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist