Provider Demographics
NPI:1417030065
Name:RANDALL, THOMAS MERTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MERTON
Last Name:RANDALL
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 1:3707 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3610
Mailing Address - Country:US
Mailing Address - Phone:517-482-1924
Mailing Address - Fax:517-485-9331
Practice Address - Street 1:3707 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3610
Practice Address - Country:US
Practice Address - Phone:517-482-1924
Practice Address - Fax:517-485-9331
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010088741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice