Provider Demographics
NPI:1467733030
Name:RANDOLPH, KATELYN M (RDH)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4222
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-4222
Mailing Address - Country:US
Mailing Address - Phone:719-480-3822
Mailing Address - Fax:
Practice Address - Street 1:220 E COLORADO AVE
Practice Address - Street 2:STE 106
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435
Practice Address - Country:US
Practice Address - Phone:719-480-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906109124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist