Provider Demographics
NPI:1558453126
Name:CALLISON, RANDALL L (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:CALLISON
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 1:124 SANTA MONICA DR
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75156-4130
Mailing Address - Country:US
Mailing Address - Phone:903-887-0383
Mailing Address - Fax:
Practice Address - Street 1:1401 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-3137
Practice Address - Country:US
Practice Address - Phone:972-932-2311
Practice Address - Fax:972-932-4767
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice