Healthcare Provider Details

I. General information

NPI: 1215917174
Provider Name (Legal Business Name): BENJAMIN J. MCGOVERN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 31401
APO AE
09630-1401
US

IV. Provider business mailing address

CMR 427 BOX 2875
APO AE
09630-0029
US

V. Phone/Fax

Practice location:
  • Phone: 314-636-9408
  • Fax:
Mailing address:
  • Phone: 314-636-9408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22273
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: