Provider Demographics
NPI:1336317601
Name:RANDOLPH L. KIXMILLER,DDS,PA
Entity Type:Organization
Organization Name:RANDOLPH L. KIXMILLER,DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIXMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-342-4014
Mailing Address - Street 1:212 S TRYON ST
Mailing Address - Street 2:#1502
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28281-0001
Mailing Address - Country:US
Mailing Address - Phone:704-342-4014
Mailing Address - Fax:
Practice Address - Street 1:212 S TRYON ST
Practice Address - Street 2:#1502
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28281-0001
Practice Address - Country:US
Practice Address - Phone:704-342-4014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty