Provider Demographics
NPI:1538672837
Name:GIOVANINI, ANGELO B (LD)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:B
Last Name:GIOVANINI
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 12TH AVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6182
Mailing Address - Country:US
Mailing Address - Phone:208-467-1107
Mailing Address - Fax:208-461-2633
Practice Address - Street 1:1611 12TH AVE RD STE B
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6182
Practice Address - Country:US
Practice Address - Phone:208-467-1107
Practice Address - Fax:208-461-2633
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD115122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist