Provider Demographics
NPI:1629134044
Name:SIPP, RANDALL W (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:W
Last Name:SIPP
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 1:2715 W FAIRBANKS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3327
Mailing Address - Country:US
Mailing Address - Phone:407-628-0111
Mailing Address - Fax:407-740-8836
Practice Address - Street 1:2715 W FAIRBANKS AVE STE 100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3327
Practice Address - Country:US
Practice Address - Phone:407-628-0111
Practice Address - Fax:407-740-8836
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN124061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice