Provider Demographics
NPI:1609883578
Name:POOLE, RANDY RAY (DDS)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:RAY
Last Name:POOLE
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 1:15 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2452
Mailing Address - Country:US
Mailing Address - Phone:319-337-2193
Mailing Address - Fax:
Practice Address - Street 1:15 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2452
Practice Address - Country:US
Practice Address - Phone:319-337-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA72261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice