Provider Demographics
NPI:1245207471
Name:JONES, RANDALL STEPHON (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:STEPHON
Last Name:JONES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053B FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3859
Mailing Address - Country:US
Mailing Address - Phone:704-393-3911
Mailing Address - Fax:704-393-3911
Practice Address - Street 1:3053B FREEDOM DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3859
Practice Address - Country:US
Practice Address - Phone:704-393-3911
Practice Address - Fax:704-393-3911
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35741223G0001X
NC83171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905629Medicaid
903ACOtherBLUE CROSS BLUE SHIELD NC