Provider Demographics
NPI:1154464519
Name:PRINCE, RANDALL PARIS (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:PARIS
Last Name:PRINCE
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 1:427 TROY AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3947
Mailing Address - Country:US
Mailing Address - Phone:731-286-1583
Mailing Address - Fax:731-287-9881
Practice Address - Street 1:427 TROY AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3947
Practice Address - Country:US
Practice Address - Phone:731-286-1583
Practice Address - Fax:731-287-9881
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS33891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0041537OtherBCBS OF TENNESSEE
TN0041537OtherBCBS OF TENNESSEE