Provider Demographics
NPI:1619159464
Name:STUART, RANDALL K (DMD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:K
Last Name:STUART
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 1:902 ECHO VALE DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-2010
Mailing Address - Country:US
Mailing Address - Phone:814-623-2217
Mailing Address - Fax:814-623-6271
Practice Address - Street 1:902 ECHO VALE DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-2010
Practice Address - Country:US
Practice Address - Phone:814-623-2217
Practice Address - Fax:814-623-6271
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028687L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017833650001Medicaid