Provider Demographics
NPI:1407105760
Name:RANDAZZO, KELLY ELAINE (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELAINE
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ELAINE
Other - Last Name:CRIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12654 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9168
Mailing Address - Country:US
Mailing Address - Phone:909-210-4597
Mailing Address - Fax:
Practice Address - Street 1:12654 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9168
Practice Address - Country:US
Practice Address - Phone:909-210-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-02
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 394124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist