Provider Demographics
NPI:1457984668
Name:GOUVEIA, KATHERINE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:GOUVEIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6014 HOBSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-1530
Mailing Address - Country:US
Mailing Address - Phone:770-238-9471
Mailing Address - Fax:
Practice Address - Street 1:5442 LAND O' LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LAND O' LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639
Practice Address - Country:US
Practice Address - Phone:813-953-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114563400Medicaid