Provider Demographics
NPI:1366606519
Name:MCGOVERN, JUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
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 1:4797 ANTIOCH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PEARSON
Mailing Address - State:GA
Mailing Address - Zip Code:31642-2850
Mailing Address - Country:US
Mailing Address - Phone:912-389-2389
Mailing Address - Fax:
Practice Address - Street 1:1370 GORDON ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3432
Practice Address - Country:US
Practice Address - Phone:912-384-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013714122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist