Provider Demographics
NPI:1881627776
Name:CARSON, KENNETH W (DDS, PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:CARSON
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 DICEY FORD RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2431
Mailing Address - Country:US
Mailing Address - Phone:803-432-4202
Mailing Address - Fax:803-432-4203
Practice Address - Street 1:400 DICEY FORD RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2431
Practice Address - Country:US
Practice Address - Phone:803-432-4202
Practice Address - Fax:803-432-4203
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ13619Medicaid