Provider Demographics
NPI:1245861749
Name:ANDERSON, REBEKAH GOULD (DMD)
Entity type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:GOULD
Last Name:ANDERSON
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 1:1807 CROWNE COMMONS WAY STE F10
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-4931
Mailing Address - Country:US
Mailing Address - Phone:843-823-3533
Mailing Address - Fax:
Practice Address - Street 1:1807 CROWNE COMMONS WAY
Practice Address - Street 2:SUITE F10
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455
Practice Address - Country:US
Practice Address - Phone:843-823-3533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9492122300000X, 1223G0001X
SC96781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty