Provider Demographics
NPI:1518264654
Name:TIESIERA, RANDALL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:TIESIERA
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:PO BOX 687
Mailing Address - Street 2:1250 OAK CIRCLE
Mailing Address - City:ARNOLD
Mailing Address - State:CA
Mailing Address - Zip Code:95223-0687
Mailing Address - Country:US
Mailing Address - Phone:209-795-1334
Mailing Address - Fax:209-795-1610
Practice Address - Street 1:1250 OAK CIRCLE
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:CA
Practice Address - Zip Code:95223
Practice Address - Country:US
Practice Address - Phone:209-795-1334
Practice Address - Fax:209-795-1610
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS26006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist