Provider Demographics
NPI:1558429399
Name:BALL, RANDY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:BALL
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 1:775 NW GILMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5374
Mailing Address - Country:US
Mailing Address - Phone:425-507-1000
Mailing Address - Fax:
Practice Address - Street 1:775 NW GILMAN BLVD
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5374
Practice Address - Country:US
Practice Address - Phone:425-507-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 605397411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics