Provider Demographics
NPI:1043852148
Name:DANIELLE M. GOUGH, DMD, PLLC
Entity type:Organization
Organization Name:DANIELLE M. GOUGH, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FANTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-218-1222
Mailing Address - Street 1:1215 W GATE DR STE 180
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-0437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1124 GALLERY PARK BOULEVARD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412
Practice Address - Country:US
Practice Address - Phone:910-218-1222
Practice Address - Fax:844-266-2407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty