Provider Demographics
NPI:1730220112
Name:GAMBRELL, ANDREW G (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:G
Last Name:GAMBRELL
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 1:9020 FARROW RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9773
Mailing Address - Country:US
Mailing Address - Phone:803-419-5002
Mailing Address - Fax:
Practice Address - Street 1:9020 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9773
Practice Address - Country:US
Practice Address - Phone:803-419-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3794332B00000X
SC037941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC57-0994852OtherTAX ID