Provider Demographics
NPI:1336134055
Name:MAYBERRY, RANDALL B (DDS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:B
Last Name:MAYBERRY
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 1:893 ROSEMONT CT
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-7154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2074 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3372
Practice Address - Country:US
Practice Address - Phone:541-851-8110
Practice Address - Fax:541-851-8114
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBM9195618OtherDEA