Provider Demographics
NPI:1417173618
Name:CAMPBELL, RANDALL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:CAMPBELL
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 1:3540 DULUTH PARK LN
Mailing Address - Street 2:SUITE 270
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6674
Mailing Address - Country:US
Mailing Address - Phone:770-497-8010
Mailing Address - Fax:770-497-8365
Practice Address - Street 1:3540 DULUTH PARK LN
Practice Address - Street 2:SUITE 270
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6674
Practice Address - Country:US
Practice Address - Phone:770-497-8010
Practice Address - Fax:770-497-8365
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00342372AMedicaid