Provider Demographics
NPI:1558437574
Name:SMITH, RANDALL B (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:B
Last Name:SMITH
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:PARKER INDIAN HEALTH CERNTER
Mailing Address - Street 2:12033 AGENCY RD.
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344
Mailing Address - Country:US
Mailing Address - Phone:928-669-3162
Mailing Address - Fax:
Practice Address - Street 1:PARKER INDIAN HEALTH CERNTER
Practice Address - Street 2:12033 AGENCY RD.
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344
Practice Address - Country:US
Practice Address - Phone:928-669-3162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.019485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist