Provider Demographics
NPI:1558543249
Name:SMILE CENTER OF KNIGHTSVILLE
Entity Type:Organization
Organization Name:SMILE CENTER OF KNIGHTSVILLE
Other - Org Name:SMILE CENTER OF KNIGHTSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:GOURDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-261-0123
Mailing Address - Street 1:100 OMALLEY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-5635
Mailing Address - Country:US
Mailing Address - Phone:843-261-0123
Mailing Address - Fax:843-261-0125
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4061Medicaid