Provider Demographics
NPI:1518038017
Name:DR RANDALL J EGGERT DDS PS
Entity Type:Organization
Organization Name:DR RANDALL J EGGERT DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:EGGERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PS
Authorized Official - Phone:425-882-9116
Mailing Address - Street 1:8575 164TH AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3679
Mailing Address - Country:US
Mailing Address - Phone:425-882-9116
Mailing Address - Fax:425-882-9136
Practice Address - Street 1:8575 164TH AVE NE
Practice Address - Street 2:SUITE 300
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3679
Practice Address - Country:US
Practice Address - Phone:425-882-9116
Practice Address - Fax:425-882-9136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000075831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU64869Medicare UPIN