Provider Demographics
NPI:1336122852
Name:PEARSON, RANDOLPH C (DDS)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:C
Last Name:PEARSON
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:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:WAITSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:99361-0445
Mailing Address - Country:US
Mailing Address - Phone:509-337-8881
Mailing Address - Fax:
Practice Address - Street 1:121 W POPLAR ST
Practice Address - Street 2:STE C
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2871
Practice Address - Country:US
Practice Address - Phone:509-525-2850
Practice Address - Fax:509-529-6545
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA49671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5512702Medicaid
WAAB18343Medicare ID - Type Unspecified