Provider Demographics
NPI:1215215439
Name:GAUTHIER, SERGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SERGE
Middle Name:
Last Name:GAUTHIER
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-0158
Mailing Address - Country:US
Mailing Address - Phone:404-451-4888
Mailing Address - Fax:
Practice Address - Street 1:513 RED BANK RD
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-4507
Practice Address - Country:US
Practice Address - Phone:843-797-1161
Practice Address - Fax:843-797-1162
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.7059 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX7059Medicaid