Provider Demographics
NPI:1598772972
Name:CHAMBERS, RANDALL WAYNE II (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WAYNE
Last Name:CHAMBERS
Suffix:II
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 1:6200 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6930
Mailing Address - Country:US
Mailing Address - Phone:616-949-4650
Mailing Address - Fax:616-949-5377
Practice Address - Street 1:6200 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6930
Practice Address - Country:US
Practice Address - Phone:616-949-4650
Practice Address - Fax:616-949-5377
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901017043OtherDENTIST LICENSE
383605922OtherFEDERAL TAX ID