Provider Demographics
NPI:1568802510
Name:MCDONOUGH, LAUREN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:A
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 NW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2106
Mailing Address - Country:US
Mailing Address - Phone:772-224-3090
Mailing Address - Fax:772-878-6350
Practice Address - Street 1:1679 NW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2106
Practice Address - Country:US
Practice Address - Phone:772-224-3090
Practice Address - Fax:772-878-6350
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03993122300000X
FLDN20301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist