Provider Demographics
NPI:1861989121
Name:MARIANO, LOGAN (DMD)
Entity type:Individual
Prefix:DR
First Name:LOGAN
Middle Name:
Last Name:MARIANO
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 1:4383 E ROSEMONTE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-3407
Mailing Address - Country:US
Mailing Address - Phone:570-772-3267
Mailing Address - Fax:
Practice Address - Street 1:4383 E ROSEMONTE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3407
Practice Address - Country:US
Practice Address - Phone:570-772-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-21
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0103641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty