Provider Demographics
NPI:1700025673
Name:RANDOL, CLIFFORD RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:RICHARD
Last Name:RANDOL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:CLIFF
Other - Middle Name:RICHARD
Other - Last Name:RANDOL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3131 N 70TH ST APT 3025
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6395
Mailing Address - Country:US
Mailing Address - Phone:541-868-5887
Mailing Address - Fax:
Practice Address - Street 1:4550 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7610
Practice Address - Country:US
Practice Address - Phone:541-868-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0079951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice