Provider Demographics
NPI:1386865350
Name:DANNELLY, GORDON DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:DAVID
Last Name:DANNELLY
Suffix:
Gender:M
Credentials:DMD
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 1668
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-1668
Mailing Address - Country:US
Mailing Address - Phone:864-859-0103
Mailing Address - Fax:864-859-0420
Practice Address - Street 1:701 BRUSHY CREEK ROAD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642
Practice Address - Country:US
Practice Address - Phone:864-859-0103
Practice Address - Fax:864-859-0420
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist