Provider Demographics
NPI:1629099916
Name:GRIFFIN, RANDALL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:GRIFFIN
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 1:11501 CUMBERLAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7005
Mailing Address - Country:US
Mailing Address - Phone:317-578-1414
Mailing Address - Fax:317-578-1417
Practice Address - Street 1:11501 CUMBERLAND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7005
Practice Address - Country:US
Practice Address - Phone:317-578-1414
Practice Address - Fax:317-578-1417
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ120097181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200139090AMedicaid