1174614465 NPI number — DR. LAUREN M GOVERNALE DMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174614465 NPI number — DR. LAUREN M GOVERNALE DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOVERNALE
Provider First Name:
LAUREN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOVERNALE
Provider Other First Name:
LAUREN
Provider Other Middle Name:
MARILYNN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1174614465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1907 COUNTESS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34110-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-592-7609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7007 LELY CULTURAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34113-8976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-775-3052
Provider Business Practice Location Address Fax Number:
239-775-7035
Provider Enumeration Date:
09/28/2006

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: 1223P0221X , with the licence number:  DN10507 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0758132 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 075813200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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