Provider Demographics
NPI:1659461432
Name:JOSEPHSON, RANDY T
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:T
Last Name:JOSEPHSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:T
Other - Last Name:JOSEPHSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2125 GAZELLE RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6568
Mailing Address - Country:US
Mailing Address - Phone:505-891-3277
Mailing Address - Fax:
Practice Address - Street 1:6301 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5860
Practice Address - Country:US
Practice Address - Phone:505-345-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM12811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice