Healthcare Provider Details

I. General information

NPI: 1447290960
Provider Name (Legal Business Name): GARY TILLERY APPLEWHITE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 FORNEY ST
FORT JACKSON SC
29207-5604
US

IV. Provider business mailing address

3295 FORNEY ST
FORT JACKSON SC
29207-5604
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-6213
  • Fax: 803-751-6886
Mailing address:
  • Phone: 803-751-6213
  • Fax: 803-751-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5257
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: