Provider Demographics
NPI:1114306750
Name:TOWER DENTAL, LLC
Entity Type:Organization
Organization Name:TOWER DENTAL, LLC
Other - Org Name:TOWER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-470-0333
Mailing Address - Street 1:330 ROBERT SMALLS PKWY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-4237
Mailing Address - Country:US
Mailing Address - Phone:843-470-0333
Mailing Address - Fax:
Practice Address - Street 1:330 ROBERT SMALLS PKWY
Practice Address - Street 2:SUITE 11
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-4237
Practice Address - Country:US
Practice Address - Phone:843-470-0333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty