Provider Demographics
NPI:1598826265
Name:RANDALL, GREGORY THOMAS (DDS)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:THOMAS
Last Name:RANDALL
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 1:212 W STATE ROAD
Mailing Address - Street 2:STE A
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058
Mailing Address - Country:US
Mailing Address - Phone:269-948-6684
Mailing Address - Fax:269-948-4644
Practice Address - Street 1:212 W STATE ROAD
Practice Address - Street 2:STE A
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058
Practice Address - Country:US
Practice Address - Phone:269-948-6684
Practice Address - Fax:269-948-4644
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0171591223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics