Provider Demographics
NPI:1417014143
Name:MATHIAS, EUGENE
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:
Last Name:MATHIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 80TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4975
Mailing Address - Country:US
Mailing Address - Phone:262-697-0825
Mailing Address - Fax:262-697-0116
Practice Address - Street 1:3410 80TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4975
Practice Address - Country:US
Practice Address - Phone:262-697-0825
Practice Address - Fax:262-697-0116
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice