Provider Demographics
NPI:1154166536
Name:BOUKER, LOGAN ALI (DMD)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:ALI
Last Name:BOUKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 STONE ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1443
Mailing Address - Country:US
Mailing Address - Phone:847-749-6570
Mailing Address - Fax:
Practice Address - Street 1:117 SOUTHPOINT LOOP STE 400
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-8899
Practice Address - Country:US
Practice Address - Phone:128-181-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist