Provider Demographics
NPI:1053326538
Name:RANDLE T. CARR, DDS, P.S.
Entity Type:Organization
Organization Name:RANDLE T. CARR, DDS, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDLE
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-734-9926
Mailing Address - Street 1:3400 SQUALICUM PKWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1933
Mailing Address - Country:US
Mailing Address - Phone:360-734-9926
Mailing Address - Fax:360-734-0855
Practice Address - Street 1:3400 SQUALICUM PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1933
Practice Address - Country:US
Practice Address - Phone:360-734-9926
Practice Address - Fax:360-734-0855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000081371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602-330-302OtherWA UBI NUMBER
WA5038815Medicaid