Provider Demographics
NPI:1205454725
Name:GOV, FIONNA TAY (DMD)
Entity type:Individual
Prefix:DR
First Name:FIONNA
Middle Name:TAY
Last Name:GOV
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 1:902 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-6441
Mailing Address - Country:US
Mailing Address - Phone:712-325-1990
Mailing Address - Fax:
Practice Address - Street 1:902 S 6TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-6441
Practice Address - Country:US
Practice Address - Phone:712-325-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7991122300000X
IADDS-10194122300000X, 1223G0001X
TX36299122300000X
FL25582122300000X
CA108663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist