Provider Demographics
NPI:1073762530
Name:RANDOLPH, ELMO R (DMD)
Entity Type:Individual
Prefix:
First Name:ELMO
Middle Name:R
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-3115
Mailing Address - Country:US
Mailing Address - Phone:973-674-8180
Mailing Address - Fax:973-676-5020
Practice Address - Street 1:462 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-3115
Practice Address - Country:US
Practice Address - Phone:973-674-8180
Practice Address - Fax:973-676-5020
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ140341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice