Provider Demographics
NPI:1518644723
Name:BREWER, RANDELL B (DMD)
Entity Type:Individual
Prefix:
First Name:RANDELL
Middle Name:B
Last Name:BREWER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 BEECHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-5402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14662 N US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-6425
Practice Address - Country:US
Practice Address - Phone:606-526-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY109391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice