Provider Demographics
NPI:1427226984
Name:J. RANDALL LATTA, DDS & ASSOCIATES, PA
Entity Type:Organization
Organization Name:J. RANDALL LATTA, DDS & ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-305-1286
Mailing Address - Street 1:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28802-1110
Mailing Address - Country:US
Mailing Address - Phone:252-305-1286
Mailing Address - Fax:
Practice Address - Street 1:3179 SWEETEN CREEK RD
Practice Address - Street 2:SUITE D
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2115
Practice Address - Country:US
Practice Address - Phone:252-305-1286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-95125Medicaid