Provider Demographics
NPI:1003236134
Name:CHICKINELL, EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:CHICKINELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8160
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0381
Mailing Address - Country:US
Mailing Address - Phone:541-469-4995
Mailing Address - Fax:541-469-4408
Practice Address - Street 1:548 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-8982
Practice Address - Country:US
Practice Address - Phone:541-469-4995
Practice Address - Fax:541-469-4408
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD4605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist