Provider Demographics
NPI:1427014786
Name:GOURDINE, JEANINE ALICIA (DMD)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:ALICIA
Last Name:GOURDINE
Suffix:
Gender:F
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:PO BOX 1090
Mailing Address - Street 2:SUITE B
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:
Practice Address - Street 1:100 OMALLEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5635
Practice Address - Country:US
Practice Address - Phone:843-261-0123
Practice Address - Fax:843-261-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4061Medicaid