=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295992436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M G DENTAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2008
-----------------------------------------------------
Last Update Date | 05/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 GASLIGHT BLVD STE C
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-3153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-632-0077
-----------------------------------------------------
Fax | 936-632-0079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 154407
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75915-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-632-0077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MYRA LYNN GOCHNOUR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 281-455-1485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13030
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------