Provider Demographics
NPI:1356684161
Name:MCGUTCHEN, GWYN GORDON
Entity Type:Individual
Prefix:DR
First Name:GWYN
Middle Name:GORDON
Last Name:MCGUTCHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 220
Mailing Address - Street 2:3681 SPIVEY STEET,
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569
Mailing Address - Country:US
Mailing Address - Phone:843-756-5747
Mailing Address - Fax:843-756-5749
Practice Address - Street 1:3681 SPIVEY ST.
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569
Practice Address - Country:US
Practice Address - Phone:843-756-5747
Practice Address - Fax:843-756-5749
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice