Provider Demographics
NPI:1952806507
Name:MCGOVERN, DANIEL (DMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MCGOVERN
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 1:4141 RINGGOLD RD
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2465
Mailing Address - Country:US
Mailing Address - Phone:229-886-3844
Mailing Address - Fax:
Practice Address - Street 1:4141 RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-698-3607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN015650390200000X
TN11033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program