Provider Demographics
NPI:1518069533
Name:MCCLINTOCK, EUGENE LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:LEROY
Last Name:MCCLINTOCK
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 399
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:IA
Mailing Address - Zip Code:50220
Mailing Address - Country:US
Mailing Address - Phone:515-465-5170
Mailing Address - Fax:515-465-5573
Practice Address - Street 1:1212 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:IA
Practice Address - Zip Code:50220-0399
Practice Address - Country:US
Practice Address - Phone:515-465-5170
Practice Address - Fax:515-465-5573
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0013177Medicaid