Provider Demographics
NPI:1699772970
Name:MICKEY, EUGENE A (DMD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:A
Last Name:MICKEY
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 1:67 MONTVALE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3618
Mailing Address - Country:US
Mailing Address - Phone:781-279-2400
Mailing Address - Fax:781-279-4640
Practice Address - Street 1:67 MONTVALE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3618
Practice Address - Country:US
Practice Address - Phone:781-279-2400
Practice Address - Fax:781-279-4640
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA142751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry