Provider Demographics
NPI:1710093570
Name:GOVIN, GUSTAVO LAWRENCE III (DDS MS)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:LAWRENCE
Last Name:GOVIN
Suffix:III
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 DUNLOUP
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804
Mailing Address - Country:US
Mailing Address - Phone:405-275-1252
Mailing Address - Fax:405-275-4292
Practice Address - Street 1:18 DUNLOUP
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-275-1252
Practice Address - Fax:405-275-4292
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery