Provider Demographics
NPI:1568884229
Name:BRYAN RANDOLPH DDS A PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:BRYAN RANDOLPH DDS A PROFESSIONAL DENTAL CORP.
Other - Org Name:THE TOOTH STATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-419-0020
Mailing Address - Street 1:1954 DEL PASO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-7706
Mailing Address - Country:US
Mailing Address - Phone:916-419-0020
Mailing Address - Fax:916-419-6787
Practice Address - Street 1:1954 DEL PASO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-7706
Practice Address - Country:US
Practice Address - Phone:916-419-0020
Practice Address - Fax:916-419-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41779261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental