Provider Demographics
NPI:1639264658
Name:SMITH, RANDALL B (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:B
Last Name:SMITH
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 1:1848 S. MILLENNIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-888-2026
Mailing Address - Fax:208-888-2094
Practice Address - Street 1:1848 S MILLENIUM WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-888-2026
Practice Address - Fax:208-888-2094
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-31691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805033400Medicaid