Provider Demographics
NPI:1649228057
Name:PENN, RANDALL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:R
Last Name:PENN
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 1:8906 COMMERCE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382
Mailing Address - Country:US
Mailing Address - Phone:248-363-5900
Mailing Address - Fax:248-363-4917
Practice Address - Street 1:8906 COMMERCE RD
Practice Address - Street 2:STE 1
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382
Practice Address - Country:US
Practice Address - Phone:248-363-5900
Practice Address - Fax:248-363-4917
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010127611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
5637323Medicare ID - Type Unspecified
T82921Medicare UPIN