Provider Demographics
NPI:1003016833
Name:RANDOLPH, LAURA ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N FRANKLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-1609
Mailing Address - Country:US
Mailing Address - Phone:201-327-1976
Mailing Address - Fax:
Practice Address - Street 1:116 N FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1609
Practice Address - Country:US
Practice Address - Phone:201-327-1976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017761001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice