Provider Demographics
NPI:1134143050
Name:DAVIS, RANDY N (DDS)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:N
Last Name:DAVIS
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 1:1133 COLLEGE AVE
Mailing Address - Street 2:STE A 103
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-539-0804
Mailing Address - Fax:785-587-9810
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:STE A 103
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-539-0804
Practice Address - Fax:785-587-9810
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice