Provider Demographics
NPI:1184636110
Name:FREED, RANDALL N (DMD, FAGD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:N
Last Name:FREED
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12887 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5813
Mailing Address - Country:US
Mailing Address - Phone:503-646-9687
Mailing Address - Fax:503-619-0066
Practice Address - Street 1:12887 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5813
Practice Address - Country:US
Practice Address - Phone:503-646-9687
Practice Address - Fax:503-619-0066
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR51711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice