Provider Demographics
NPI:1124037924
Name:SORENSEN, RANDY LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LEE
Last Name:SORENSEN
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 1:939 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5057
Mailing Address - Country:US
Mailing Address - Phone:208-746-2668
Mailing Address - Fax:
Practice Address - Street 1:939 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5057
Practice Address - Country:US
Practice Address - Phone:208-746-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist