Provider Demographics
NPI:1164589107
Name:RANDOLPH, CHARLES D (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:RANDOLPH
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 1:875 MAMARONECK AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1900
Mailing Address - Country:US
Mailing Address - Phone:914-835-6004
Mailing Address - Fax:914-835-6055
Practice Address - Street 1:875 MAMARONECK AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1900
Practice Address - Country:US
Practice Address - Phone:914-835-6004
Practice Address - Fax:914-835-6055
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0281371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02577842Medicaid