Basic Information
Provider Information | |||||||||
NPI: | 1841210572 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOGELIN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | GREGORY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3757 CAMINO BELLA ROSA | ||||||||
Address2: |   | ||||||||
City: | SIERRA VISTA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856509410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023268519 | ||||||||
FaxNumber: | 5203789982 | ||||||||
Practice Location | |||||||||
Address1: | BLDG 45005 RUNION DENTAL CLINIC | ||||||||
Address2: | USA DENTAC | ||||||||
City: | FT HUACHUCA | ||||||||
State: | AZ | ||||||||
PostalCode: | 85670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205333144 | ||||||||
FaxNumber: | 5205337285 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 28353 | CA | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | 3481 | NV | Y |   | Dental Providers | Dentist | General Practice | 1223G0001X | 9858 | CO | N |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 32170513 | 05 | CO |   | MEDICAID | D28353 | 05 | CA |   | MEDICAID | 002202771 | 05 | NV |   | MEDICAID |