Provider Demographics
NPI:1447360854
Name:CAROLINA CENTER FOR RESTORATIVE DENTISTRY
Entity type:Organization
Organization Name:CAROLINA CENTER FOR RESTORATIVE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BARRACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-849-9044
Mailing Address - Street 1:966 SUITE I
Mailing Address - Street 2:HOUSTON NORTHCUTT BLVD
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-849-9044
Mailing Address - Fax:843-849-7493
Practice Address - Street 1:966 SUITE I
Practice Address - Street 2:HOUSTON NORTHCUTT BLVD
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-849-9044
Practice Address - Fax:843-849-7493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1831223P0300X
SC41696211223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
45955353OtherTPIN