Provider Demographics
NPI:1164797031
Name:BETHEA, GARY A (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:BETHEA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8190
Mailing Address - Country:US
Mailing Address - Phone:803-773-5413
Mailing Address - Fax:
Practice Address - Street 1:625 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8190
Practice Address - Country:US
Practice Address - Phone:803-773-5413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist