Provider Demographics
NPI:1639593254
Name:MEDICAL UNIVERSITY OF SOUTH CAROLINA
Entity Type:Organization
Organization Name:MEDICAL UNIVERSITY OF SOUTH CAROLINA
Other - Org Name:THERESA SULLIVAN GONZALES DMD MS MSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-792-4496
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-3911
Practice Address - Street 1:173 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-4496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty