Provider Demographics
NPI:1609896331
Name:RANDALL, SAMUEL JOHN III (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOHN
Last Name:RANDALL
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6842 MORRISON BLVD.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-442-7175
Mailing Address - Fax:704-442-7231
Practice Address - Street 1:6842 MORRISON BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3547
Practice Address - Country:US
Practice Address - Phone:704-442-7175
Practice Address - Fax:704-442-7231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC43931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice