Healthcare Provider Details

I. General information

NPI: 1972600989
Provider Name (Legal Business Name): GORDON W WOMACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 TANNER FORD BLVD
HANAHAN SC
29410-4780
US

IV. Provider business mailing address

102 VIEW ST
MONCKS CORNER SC
29461-9783
US

V. Phone/Fax

Practice location:
  • Phone: 843-212-8810
  • Fax:
Mailing address:
  • Phone: 843-214-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDGD.9455GD
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number17287
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number17287
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDGD.2025DS
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: