Provider Demographics
NPI:1477607455
Name:THOMAS, RANDOLPH P (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:P
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:CHURCH HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37642-0349
Mailing Address - Country:US
Mailing Address - Phone:423-357-7111
Mailing Address - Fax:423-357-1991
Practice Address - Street 1:108 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHURCH HILL
Practice Address - State:TN
Practice Address - Zip Code:37642-3723
Practice Address - Country:US
Practice Address - Phone:423-357-7111
Practice Address - Fax:423-357-1991
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0033971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2007056OtherBLUECROSS BLUESHIELD TN