Provider Demographics
NPI:1841248382
Name:RUCKER, CARLTON D (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLTON
Middle Name:D
Last Name:RUCKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 SPRINGCREST DR STE A
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7324
Mailing Address - Country:US
Mailing Address - Phone:803-547-1888
Mailing Address - Fax:803-547-8533
Practice Address - Street 1:575 SPRINGCREST DR STE A
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7324
Practice Address - Country:US
Practice Address - Phone:803-547-1888
Practice Address - Fax:803-547-8533
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3742Medicaid