Provider Demographics
NPI:1164465399
Name:COFFEE, LOGAN WAYNE
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:WAYNE
Last Name:COFFEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:VIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74962-0412
Mailing Address - Country:US
Mailing Address - Phone:918-773-6200
Mailing Address - Fax:918-773-6201
Practice Address - Street 1:HIGHWAY 83 SOUTH AND I-40 JUNCTION
Practice Address - Street 2:
Practice Address - City:VIAN
Practice Address - State:OK
Practice Address - Zip Code:74962
Practice Address - Country:US
Practice Address - Phone:918-773-6200
Practice Address - Fax:918-773-6201
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice