Provider Demographics
NPI:1366821183
Name:VEATH, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:VEATH
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 1:2105 PINE ST
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-1850
Mailing Address - Country:US
Mailing Address - Phone:407-755-5342
Mailing Address - Fax:
Practice Address - Street 1:2105 PINE ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-1850
Practice Address - Country:US
Practice Address - Phone:407-755-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1043443260Medicaid