Provider Demographics
NPI:1235570961
Name:CLASEN, RANDALL SCOTT (LD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:CLASEN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 NE WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3260
Mailing Address - Country:US
Mailing Address - Phone:541-673-2724
Mailing Address - Fax:547-440-6906
Practice Address - Street 1:696 NE WINCHESTER ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3260
Practice Address - Country:US
Practice Address - Phone:541-673-2724
Practice Address - Fax:547-440-6906
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO355212122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR86-114979OtherTAX ID