Provider Demographics
NPI:1780772558
Name:HUMPHRIES, EUGENE (DDS)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:HUMPHRIES
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 1:18000 PIONEER BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4416
Mailing Address - Country:US
Mailing Address - Phone:562-860-1333
Mailing Address - Fax:
Practice Address - Street 1:18000 PIONEER BLVD STE 207
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-4416
Practice Address - Country:US
Practice Address - Phone:562-860-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB21371-01OtherDENTI-CAL PROVIDER ID #