Provider Demographics
NPI:1619067048
Name:TOLOCKO, RANDALL LEO (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEO
Last Name:TOLOCKO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E LINE ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3504
Mailing Address - Country:US
Mailing Address - Phone:760-873-5191
Mailing Address - Fax:760-873-4040
Practice Address - Street 1:306 E LINE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3504
Practice Address - Country:US
Practice Address - Phone:760-873-5191
Practice Address - Fax:760-873-4040
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA317171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice