Provider Demographics
NPI:1114380441
Name:FOX-GOUGHAN, NANCY (RDH)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FOX-GOUGHAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:GOUGHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:22128 BRADDOCK PL
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4292
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 CLINT MOORE RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2800
Practice Address - Country:US
Practice Address - Phone:561-642-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22373124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist