Provider Demographics
NPI:1275026874
Name:BOOTH, RANDY (DMD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BOOTH
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 1:3805 PENNINE WAY
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 GENERAL CAVAZOS BLVD STE C
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7148
Practice Address - Country:US
Practice Address - Phone:361-595-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice