MEDICARE: JESSICA JANE EUGENIO DMD

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	122300000X	Dentist	7191	KY

General Provider Information

NPI Number	:	1730160698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA JANE EUGENIO DMD

Provider Business Mailing Address
First Line	:	130 STONECREST RD STE 101
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-8126
Country	:	US
Telephone Number	:	502-633-1584
Fax Number	:	502-633-1509

Provider Business Practice Location Address
First Line	:	130 STONECREST RD
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-8126
Country	:	US
Telephone Number	:	502-633-1584
Fax Number	:	502-633-1509

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	09/23/2008

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