Provider Demographics
NPI:1861671414
Name:MCDONOUGH, ANN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:MARIE
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 1:25 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644
Mailing Address - Country:US
Mailing Address - Phone:570-693-1164
Mailing Address - Fax:570-693-1890
Practice Address - Street 1:25 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644
Practice Address - Country:US
Practice Address - Phone:570-693-1164
Practice Address - Fax:570-693-1890
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019875550001Medicaid