Provider Demographics
NPI:1154451003
Name:DIEZ, RANDALL ALBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALBERT
Last Name:DIEZ
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 1:5010 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6322
Mailing Address - Country:US
Mailing Address - Phone:813-960-5869
Mailing Address - Fax:813-968-7578
Practice Address - Street 1:5010 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-6322
Practice Address - Country:US
Practice Address - Phone:813-960-5869
Practice Address - Fax:813-968-7578
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00104751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice