Healthcare Provider Details

I. General information

NPI: 1750581682
Provider Name (Legal Business Name): RUSSELL B MCCRACKEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 N KINGS HWY # 106
MYRTLE BEACH SC
29577-3636
US

IV. Provider business mailing address

1317 N KINGS HWY # 106
MYRTLE BEACH SC
29577-3636
US

V. Phone/Fax

Practice location:
  • Phone: 843-626-5437
  • Fax:
Mailing address:
  • Phone: 843-626-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4282
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: