Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D4605 | OR |
NPI | 1003236134 |
---|---|
Provider Name | Eugene Chickinell |
First Address | Brookings, OR 97415-0381 |
Second Address | Brookings, OR 97415-8982 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2014 |
Last Update Date | 16/04/2014 |