Provider Demographics
NPI:1467457853
Name:BENNER, RANDALL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:R
Last Name:BENNER
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 1:1940 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6524
Mailing Address - Country:US
Mailing Address - Phone:229-985-7222
Mailing Address - Fax:229-891-2640
Practice Address - Street 1:1940 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6524
Practice Address - Country:US
Practice Address - Phone:229-985-7222
Practice Address - Fax:229-891-2640
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist