1063521680 NPI number — MR. EUGENE JUSTIN GOMES III DDS

Table of content: MR. EUGENE JUSTIN GOMES III DDS (NPI 1063521680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063521680 NPI number — MR. EUGENE JUSTIN GOMES III DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMES
Provider First Name:
EUGENE
Provider Middle Name:
JUSTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063521680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23029
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-861-9123
Provider Business Mailing Address Fax Number:
612-861-9155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1866 BEAM AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-774-7144
Provider Business Practice Location Address Fax Number:
651-770-0560
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D 11118 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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