Healthcare Provider Details

I. General information

NPI: 1831274539
Provider Name (Legal Business Name): KENNETH P RASENBERGER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8734 UNIVERSITY CITY BLVD
CHARLOTTE NC
28213-3558
US

IV. Provider business mailing address

8734 UNIVERSITY CITY BLVD
CHARLOTTE NC
28213-3558
US

V. Phone/Fax

Practice location:
  • Phone: 704-549-4991
  • Fax: 704-549-0135
Mailing address:
  • Phone: 704-549-4991
  • Fax: 704-549-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: