Provider Demographics
NPI:1609188531
Name:RANDALL, GRADY S (DDS)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:S
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 1:1179 E PARIS AVE SE STE 130
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-942-9840
Mailing Address - Fax:616-942-0170
Practice Address - Street 1:1179 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8371
Practice Address - Country:US
Practice Address - Phone:616-942-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002018491223P0221X
MI29010225701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry