Provider Demographics
NPI:1326352071
Name:RANDALL M STUCKI FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:RANDALL M STUCKI FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:MCKAY
Authorized Official - Last Name:STUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-636-5455
Mailing Address - Street 1:75 W MAIN STREET CT STE 200
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-5602
Mailing Address - Country:US
Mailing Address - Phone:801-636-5455
Mailing Address - Fax:801-492-7728
Practice Address - Street 1:75 W MAIN STREET CT STE 200
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-5602
Practice Address - Country:US
Practice Address - Phone:801-636-5455
Practice Address - Fax:801-492-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1454049922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty