Provider Demographics
NPI:1437233137
Name:PAGENKOPF, RANDALL JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:PAGENKOPF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 LONG POINT RD # A
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8226
Mailing Address - Country:US
Mailing Address - Phone:843-971-6221
Mailing Address - Fax:843-971-3810
Practice Address - Street 1:757 LONG POINT RD # A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8226
Practice Address - Country:US
Practice Address - Phone:843-971-6221
Practice Address - Fax:843-971-3810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ35463Medicaid