Basic Information
| Provider Information | |||||||||
| NPI: | 1356435127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 RUTLEDGE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294034145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437239582 | ||||||||
| FaxNumber: | 8437237011 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 RUTLEDGE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294034145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437239582 | ||||||||
| FaxNumber: | 8437237011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2778 | SC | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | TAX ID NUMBER | 01 | SC | 571088293 | OTHER | Z27784 | 05 | SC | MEDICAID | 2778 | 01 | SC | STATE LICENSE NUMBER | OTHER |