Provider Demographics
NPI:1003815655
Name:BREEN, RANDY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JAMES
Last Name:BREEN
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 1:2435 ROLLING MEADOW DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9332
Mailing Address - Country:US
Mailing Address - Phone:616-863-9515
Mailing Address - Fax:
Practice Address - Street 1:515 LAKESIDE DR SE
Practice Address - Street 2:#208
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2931
Practice Address - Country:US
Practice Address - Phone:616-454-9091
Practice Address - Fax:616-454-1159
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-17
Last Update Date:2007-07-08
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MI29010140551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice