Provider Demographics
NPI:1053826057
Name:EG DMD, LLC
Entity Type:Organization
Organization Name:EG DMD, LLC
Other - Org Name:HAMPTON DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EMERSON
Authorized Official - Middle Name:F
Authorized Official - Last Name:GOWER
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-943-4895
Mailing Address - Street 1:23 GREETERS LN
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7027
Mailing Address - Country:US
Mailing Address - Phone:843-621-1104
Mailing Address - Fax:
Practice Address - Street 1:649 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-4757
Practice Address - Country:US
Practice Address - Phone:803-943-4895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7047261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX7047Medicaid