Healthcare Provider Details

I. General information

NPI: 1316322167
Provider Name (Legal Business Name): LOGAN KAY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BENNETT AVE
BURLEY ID
83318-2676
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-7447
  • Fax:
Mailing address:
  • Phone: 208-734-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4672
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: