Provider Demographics
NPI:1336119775
Name:AVERS, RANDALL J (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:J
Last Name:AVERS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21402-1257
Mailing Address - Country:US
Mailing Address - Phone:410-293-4378
Mailing Address - Fax:410-293-4831
Practice Address - Street 1:250 WOOD RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21402-1257
Practice Address - Country:US
Practice Address - Phone:410-293-4378
Practice Address - Fax:410-293-4831
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-8322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN