Provider Demographics
NPI:1972884344
Name:MCGOVERN DENTAL, LLC
Entity type:Organization
Organization Name:MCGOVERN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOVERN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-384-1306
Mailing Address - Street 1:1370 GORDON ST W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-3432
Mailing Address - Country:US
Mailing Address - Phone:912-384-1306
Mailing Address - Fax:912-384-1308
Practice Address - Street 1:1370 GORDON ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3432
Practice Address - Country:US
Practice Address - Phone:912-384-1306
Practice Address - Fax:912-384-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106996AMedicaid