Provider Demographics
NPI:1518059484
Name:PITZER, RANDOLPH RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:RICHARD
Last Name:PITZER
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 1:2224 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6286
Mailing Address - Country:US
Mailing Address - Phone:701-774-0259
Mailing Address - Fax:701-774-0250
Practice Address - Street 1:2224 1ST AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6286
Practice Address - Country:US
Practice Address - Phone:701-774-0259
Practice Address - Fax:701-774-0250
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND16281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40031Medicaid
MT111332Medicaid