Provider Demographics
NPI:1326038233
Name:SPARKS, JAMES RANDALL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RANDALL
Last Name:SPARKS
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 1:205 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-1403
Mailing Address - Country:US
Mailing Address - Phone:502-222-7070
Mailing Address - Fax:502-222-7070
Practice Address - Street 1:205 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-1403
Practice Address - Country:US
Practice Address - Phone:502-222-7070
Practice Address - Fax:502-222-7070
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60045184Medicaid