Provider Demographics
NPI:1649308297
Name:GOVERNALE, NICK G (DDS)
Entity type:Individual
Prefix:DR
First Name:NICK
Middle Name:G
Last Name:GOVERNALE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:R
Other - Last Name:SPEAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:125 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5724
Mailing Address - Country:US
Mailing Address - Phone:318-352-3830
Mailing Address - Fax:318-352-5744
Practice Address - Street 1:125 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5724
Practice Address - Country:US
Practice Address - Phone:318-352-3830
Practice Address - Fax:318-352-5744
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice