Provider Demographics
NPI:1316001233
Name:RANDALL, MARK LANE (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LANE
Last Name:RANDALL
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 1:112 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3451
Mailing Address - Country:US
Mailing Address - Phone:978-534-5608
Mailing Address - Fax:
Practice Address - Street 1:16A HOLLIS ST.
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450
Practice Address - Country:US
Practice Address - Phone:978-448-6814
Practice Address - Fax:978-448-6835
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist