Provider Demographics
NPI:1720045776
Name:GOURDINE, JEFFREY CRAIG (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CRAIG
Last Name:GOURDINE
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:PO BOX 1090
Mailing Address - Street 2:
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 1:1422 BELLS HWY
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2516
Practice Address - Country:US
Practice Address - Phone:843-538-7330
Practice Address - Fax:843-538-7336
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4022Medicaid