Provider Demographics
NPI:1003878034
Name:IBARRA, RANDOLPH A (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:A
Last Name:IBARRA
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 1:8355 CRESTWAY DR
Mailing Address - Street 2:1126
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3596
Mailing Address - Country:US
Mailing Address - Phone:210-623-6112
Mailing Address - Fax:
Practice Address - Street 1:8744 GRISSOM RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4819
Practice Address - Country:US
Practice Address - Phone:210-523-0000
Practice Address - Fax:210-523-0067
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice