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General NPI Number Information
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NPI Number | 1972600989
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Entity Type | Individual
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Provider Name | GORDON W WOMACK DDS
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Gender | Male
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 996 TANNER FORD BLVD
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City | HANAHAN
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State | SC
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Zip | 29410-4780
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Country | US
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Telephone | 843-212-8810
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Fax |
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Provider Business Mailing Address
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Address Line | 102 VIEW ST
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City | MONCKS CORNER
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State | SC
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Zip | 29461-9783
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Country | US
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Telephone | 843-214-8040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DGD.9455GD
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 17287
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 17287
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DGD.2025DS
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License Number State | SC
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