Provider Demographics
NPI:1528189446
Name:DAVID F RANDOLPH DMD PA
Entity Type:Organization
Organization Name:DAVID F RANDOLPH DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-755-4033
Mailing Address - Street 1:1779 SW BARNETT WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6957
Mailing Address - Country:US
Mailing Address - Phone:386-755-4033
Mailing Address - Fax:386-755-2581
Practice Address - Street 1:1779 SW BARNETT WAY STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6957
Practice Address - Country:US
Practice Address - Phone:386-755-4033
Practice Address - Fax:386-755-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60390OtherBLUE CROSS BLUE SHIELD