Provider Demographics
NPI:1649392382
Name:DEGERNESS, RANDOLPH ALVIN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:ALVIN
Last Name:DEGERNESS
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:8340 SANGRE DE CRISTO RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-4248
Mailing Address - Country:US
Mailing Address - Phone:303-948-4884
Mailing Address - Fax:720-922-7734
Practice Address - Street 1:8340 SANGRE DE CRISTO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-4248
Practice Address - Country:US
Practice Address - Phone:303-948-4884
Practice Address - Fax:720-922-7734
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODEN0000000051491223E0200X
MND96601223E0200X
WY8991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODEN000000005149OtherLICENSE NUMBER
MND9660OtherSTATE LICENSE NUMBER
WY899OtherSTATE LICENSE NUMBER