MEDICARE: DR. CORY JAMES LOGAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	19464	TX

General Provider Information

NPI Number	:	1265529226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CORY JAMES LOGAN D.D.S.

Provider Business Mailing Address
First Line	:	6633 TELUCO ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-5359
Country	:	US
Telephone Number	:	713-290-0331
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 WAUGH DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-2002
Country	:	US
Telephone Number	:	713-942-8598
Fax Number	:	713-942-8591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	07/08/2007

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