Healthcare Provider Details

I. General information

NPI: 1396829180
Provider Name (Legal Business Name): EUGENE A MICKEY, DMD, MPH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 MONTVALE AVE SUITE 101
STONEHAM MA
02180-3618
US

IV. Provider business mailing address

67 MONTVALE AVE SUITE 101
STONEHAM MA
02180-3618
US

V. Phone/Fax

Practice location:
  • Phone: 781-279-2400
  • Fax: 781-279-4640
Mailing address:
  • Phone: 781-279-2400
  • Fax: 781-279-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14275
License Number StateMA

VIII. Authorized Official

Name: MRS. LISA A FIELD
Title or Position: OFFICE MANAGER
Credential: CDPMA
Phone: 781-279-2400