Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 1940 | SC |
N | 1223P0700X | Prosthodontist | 242 | SC |
NPI | 1265553846 |
---|---|
Provider Name | Dr. Gabriel Buchanan Ingraham III |
First Address | Kershaw, SC 29067-1403 |
Second Address | Kershaw, SC 29067-1403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2007 |
Last Update Date | 08/07/2007 |