Provider Demographics
NPI:1548785926
Name:EWING, RANDALL JASON (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JASON
Last Name:EWING
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 1:6370 CAMINITO ANDRETA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7205
Mailing Address - Country:US
Mailing Address - Phone:619-610-8217
Mailing Address - Fax:
Practice Address - Street 1:3340 KEMPER ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4908
Practice Address - Country:US
Practice Address - Phone:619-224-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1017081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice