Provider Demographics
NPI:1437231503
Name:RANDELL, JAY SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:SCOTT
Last Name:RANDELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:SCOTT
Other - Last Name:YUDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1112 NW CIRCLE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1462
Mailing Address - Country:US
Mailing Address - Phone:541-257-2006
Mailing Address - Fax:541-257-2007
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-0123
Practice Address - Fax:541-766-6186
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL132691223G0001X
CO2023681223G0001X
NY0442491223G0001X
ORD111821223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice