Provider Demographics
NPI:1538316674
Name:RANDALL, NICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:
Last Name:RANDALL
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 1:3239 E COWBOY COVE TRL
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-3298
Mailing Address - Country:US
Mailing Address - Phone:480-833-2232
Mailing Address - Fax:480-833-3062
Practice Address - Street 1:2045 S VINEYARD
Practice Address - Street 2:SUITE 153
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6889
Practice Address - Country:US
Practice Address - Phone:480-833-2232
Practice Address - Fax:480-833-3062
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist