Healthcare Provider Details

I. General information

NPI: 1447360854
Provider Name (Legal Business Name): CAROLINA CENTER FOR RESTORATIVE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 SUITE I HOUSTON NORTHCUTT BLVD
MT PLEASANT SC
29464
US

IV. Provider business mailing address

966 SUITE I HOUSTON NORTHCUTT BLVD
MT PLEASANT SC
29464
US

V. Phone/Fax

Practice location:
  • Phone: 843-849-9044
  • Fax: 843-849-7493
Mailing address:
  • Phone: 843-849-9044
  • Fax: 843-849-7493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number183
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4169621
License Number StateSC

VIII. Authorized Official

Name: DR. KENNETH STEVEN BARRACK
Title or Position: PARTNER PRESIDENT
Credential:
Phone: 843-849-9044