Provider Demographics
NPI:1659329548
Name:DAWSON, GORDON ROUX (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ROUX
Last Name:DAWSON
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 1:209 W 4TH NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6541
Mailing Address - Country:US
Mailing Address - Phone:843-873-5921
Mailing Address - Fax:843-873-5922
Practice Address - Street 1:209 W 4TH NORTH ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6541
Practice Address - Country:US
Practice Address - Phone:843-873-5921
Practice Address - Fax:843-873-5922
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9731Medicaid