MEDICARE: DR. KOURTNEY REGINA LOGAN DDS

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	1223P0221X	Pediatric Dentistry	26252	TX
2	122300000X	Dentist	26252	TX

General Provider Information

NPI Number	:	1326334269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOURTNEY REGINA LOGAN DDS

Provider Business Mailing Address
First Line	:	1811 ARMY BLVD
Second Line	:
City	:	JBSA FT SAM HOUSTON
State	:	TX
Zip	:	78234-2686
Country	:	US
Telephone Number	:	210-221-0826
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 ARMY BLVD
Second Line	:
City	:	JBSA FT SAM HOUSTON
State	:	TX
Zip	:	78234-2686
Country	:	US
Telephone Number	:	210-221-0826
Fax Number	:

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

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	03/20/2025

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