Provider Demographics
NPI:1518970789
Name:LOGAN, KERI A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KERI
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BELLE TERRE ROAD
Mailing Address - Street 2:ST. CHARLES HOSPITAL
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE ROAD
Practice Address - Street 2:ST. CHARLES HOSPITAL
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-474-6553
Practice Address - Fax:631-474-6024
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice