Provider Demographics
NPI:1871535054
Name:GAILLARDETZ, GEORGE A (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:GAILLARDETZ
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 1:1127 QUEENSBOROUGH BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5432
Mailing Address - Country:US
Mailing Address - Phone:843-352-9430
Mailing Address - Fax:843-352-9731
Practice Address - Street 1:1127 QUEENSBOROUGH BLVD STE 107
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5432
Practice Address - Country:US
Practice Address - Phone:603-569-2268
Practice Address - Fax:603-569-5837
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003379Medicaid
NH020433005OtherNE DELTA DENTAL PAYEE #