Provider Demographics
NPI:1588745459
Name:EUGENE HUMPHRIES, D.D.S.
Entity type:Organization
Organization Name:EUGENE HUMPHRIES, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:CANDACE
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-716-6244
Mailing Address - Street 1:27981 GREENFIELD DR STE F
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-1494
Mailing Address - Country:US
Mailing Address - Phone:949-362-7474
Mailing Address - Fax:949-362-0470
Practice Address - Street 1:27981 GREENFIELD DR STE F
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-1494
Practice Address - Country:US
Practice Address - Phone:949-362-7474
Practice Address - Fax:949-362-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty