Provider Demographics
NPI:1063593838
Name:HERBOSA, EUGENIO G (DMD MMSC)
Entity type:Individual
Prefix:MR
First Name:EUGENIO
Middle Name:G
Last Name:HERBOSA
Suffix:
Gender:M
Credentials:DMD MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 S BRENTWOOD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:314-721-1010
Mailing Address - Fax:314-721-5276
Practice Address - Street 1:12818 TESSON FERRY ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-842-0020
Practice Address - Fax:314-842-1590
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15229204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
23435Medicare UPIN