Healthcare Provider Details

I. General information

NPI: 1417517384
Provider Name (Legal Business Name): GAMECOCK DENTISTRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

968 INTERNATIONAL DR
MYRTLE BEACH SC
29579-3488
US

IV. Provider business mailing address

968 INTERNATIONAL DR
MYRTLE BEACH SC
29579-3488
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-8800
  • Fax:
Mailing address:
  • Phone: 843-903-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. COURTNEY HOLMES SUGGS
Title or Position: DENTIST
Credential: DMD
Phone: 843-798-1662