MEDICARE: EUGENE A MICKEY, DMD, MPH, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	14275	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38861	OTHER	MA	HPHC
2	659373	OTHER	PA	UNITED CONCORDIA
3	X10967	OTHER	MA	BCBSMA

General Provider Information

NPI Number	:	1396829180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EUGENE A MICKEY, DMD, MPH, PC

Provider Business Mailing Address
First Line	:	67 MONTVALE AVE
Second Line	:	SUITE 101
City	:	STONEHAM
State	:	MA
Zip	:	02180-3618
Country	:	US
Telephone Number	:	781-279-2400
Fax Number	:	781-279-4640

Provider Business Practice Location Address
First Line	:	67 MONTVALE AVE
Second Line	:	SUITE 101
City	:	STONEHAM
State	:	MA
Zip	:	02180-3618
Country	:	US
Telephone Number	:	781-279-2400
Fax Number	:	781-279-4640

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. LISA A FIELD
Credential	:	CDPMA
Telephone Number	:	781-279-2400

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	08/22/2020

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