Provider Demographics
NPI:1063035822
Name:COWAN, LOGAN JAYNE
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:JAYNE
Last Name:COWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-4508
Mailing Address - Country:US
Mailing Address - Phone:605-224-5966
Mailing Address - Fax:
Practice Address - Street 1:433 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-4508
Practice Address - Country:US
Practice Address - Phone:605-224-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1257122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist