Provider Demographics
NPI:1770885006
Name:WINDOM, EUGENE
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:WINDOM
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 1:10801 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-7103
Mailing Address - Country:US
Mailing Address - Phone:310-836-3476
Mailing Address - Fax:
Practice Address - Street 1:1212 MCCLELLAN DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1066
Practice Address - Country:US
Practice Address - Phone:310-838-9863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist