Provider Demographics
NPI:1811088636
Name:BOONE, EUGENE KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:KEITH
Last Name:BOONE
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 1:1316 CAROLINA ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-1444
Mailing Address - Country:US
Mailing Address - Phone:219-882-2705
Mailing Address - Fax:
Practice Address - Street 1:3616 ELM ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2270
Practice Address - Country:US
Practice Address - Phone:219-391-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120093301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice