Provider Demographics
NPI:1164631776
Name:BRYAN RANDOLPH DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:BRYAN RANDOLPH DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:916-984-6747
Mailing Address - Street 1:1621 CREEKSIDE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3493
Mailing Address - Country:US
Mailing Address - Phone:916-984-6747
Mailing Address - Fax:916-984-6746
Practice Address - Street 1:1621 CREEKSIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3493
Practice Address - Country:US
Practice Address - Phone:916-984-6747
Practice Address - Fax:916-984-6746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty