MEDICARE: DR. EUGENE KEITH BOONE D.D.S

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	1223G0001X	General Practice Dentistry	12009330	IN

General Provider Information

NPI Number	:	1811088636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EUGENE KEITH BOONE D.D.S

Provider Business Mailing Address
First Line	:	1316 CAROLINA ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46407-1444
Country	:	US
Telephone Number	:	219-882-2705
Fax Number	:

Provider Business Practice Location Address
First Line	:	3616 ELM ST
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2270
Country	:	US
Telephone Number	:	219-391-8485
Fax Number	:

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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