Provider Demographics
NPI:1972962991
Name:GAMBLE DENTALSMART PC
Entity type:Organization
Organization Name:GAMBLE DENTALSMART PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:843-735-6727
Mailing Address - Street 1:2020 SAVANNAH HWY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6286
Mailing Address - Country:US
Mailing Address - Phone:843-735-6727
Mailing Address - Fax:
Practice Address - Street 1:1988 PAXVILLE HWY
Practice Address - Street 2:SPACE #613-01
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-6432
Practice Address - Country:US
Practice Address - Phone:803-696-4432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX1626Medicaid