Provider Demographics
NPI:1629617980
Name:RANDALL NIEDERKOHR,D.D.S,INC.
Entity Type:Organization
Organization Name:RANDALL NIEDERKOHR,D.D.S,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDLL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:NIEDERKOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-816-3581
Mailing Address - Street 1:27 ST LAWRENCE DR STE 109
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8314
Mailing Address - Country:US
Mailing Address - Phone:419-447-7337
Mailing Address - Fax:419-447-7003
Practice Address - Street 1:27 ST LAWRENCE DR STE 109
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8314
Practice Address - Country:US
Practice Address - Phone:419-447-7337
Practice Address - Fax:419-447-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental