Provider Demographics
NPI:1164403515
Name:BROWN, RANDALL W (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:W
Last Name:BROWN
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 1:1600 SW ARCHER RD
Mailing Address - Street 2:D7-6
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0416
Mailing Address - Country:US
Mailing Address - Phone:352-273-6750
Mailing Address - Fax:352-392-7609
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:D7-6
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0416
Practice Address - Country:US
Practice Address - Phone:352-273-6750
Practice Address - Fax:352-392-7609
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN99961223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072402500Medicaid
FL072402500Medicaid