Provider Demographics
NPI:1659412724
Name:SMITH, RANDALL G
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:G
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:D,D,S
Mailing Address - Street 1:2805 EAGLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-542-1333
Mailing Address - Fax:208-552-7296
Practice Address - Street 1:2805 EAGLE DRIVE
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-542-1333
Practice Address - Fax:208-552-7296
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3257PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6C024OtherBLUE CROSS OF IDAHO
ID804126800Medicaid