MEDICARE: DR. GABRIEL ROSS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		OH
2	1223P0221X	Pediatric Dentistry	8574	SC
3	122300000X	Dentist	8574	SC

General Provider Information

NPI Number	:	1184043226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL ROSS DMD

Provider Business Mailing Address
First Line	:	2001 2ND AVE STE 102
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7887
Country	:	US
Telephone Number	:	843-900-4490
Fax Number	:	843-501-9450

Provider Business Practice Location Address
First Line	:	2001 2ND AVE STE 102
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7887
Country	:	US
Telephone Number	:	843-876-8815
Fax Number	:	843-876-8783

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	01/28/2022

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