Provider Demographics
NPI:1326334269
Name:LOGAN, KOURTNEY REGINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KOURTNEY
Middle Name:REGINA
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 ARMY BLVD
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2686
Mailing Address - Country:US
Mailing Address - Phone:210-221-0826
Mailing Address - Fax:
Practice Address - Street 1:1811 ARMY BLVD
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-2686
Practice Address - Country:US
Practice Address - Phone:210-221-0826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26252122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist