Provider Demographics
NPI:1184845620
Name:WING, RANDALL CARL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CARL
Last Name:WING
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 SULLIVAN AVE. SUITE A-1
Mailing Address - Street 2:
Mailing Address - City:S. WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-643-6942
Mailing Address - Fax:860-649-4347
Practice Address - Street 1:1050 SULLIVAN AVE. SUITE A-1
Practice Address - Street 2:
Practice Address - City:S. WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-643-6942
Practice Address - Fax:860-649-4347
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0077111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry