Provider Demographics
NPI:1295817518
Name:TOOTHAKER, RANDALL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WAYNE
Last Name:TOOTHAKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 COUNTRY CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:515-302-8079
Mailing Address - Fax:
Practice Address - Street 1:328 COUNTRY CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501
Practice Address - Country:US
Practice Address - Phone:515-302-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE5287OtherBC/BS