Provider Demographics
NPI:1649359746
Name:GOVERNO, MARK WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:GOVERNO
Suffix:
Gender:M
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:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:NH
Mailing Address - Zip Code:03770-0033
Mailing Address - Country:US
Mailing Address - Phone:603-443-0069
Mailing Address - Fax:
Practice Address - Street 1:2 CAMPBELL STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-448-4200
Practice Address - Fax:603-448-6424
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3123122300000X
MADN187321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
807907OtherUNITED CONDORDIA
NH30300297Medicaid