Provider Demographics
NPI:1376632430
Name:KELLY, RANDALL SHAWN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SHAWN
Last Name:KELLY
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 1:700 SUNRISE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4561
Mailing Address - Country:US
Mailing Address - Phone:916-773-1122
Mailing Address - Fax:916-773-3528
Practice Address - Street 1:700 SUNRISE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4561
Practice Address - Country:US
Practice Address - Phone:916-773-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680245059OtherTIN