Provider Demographics
NPI:1700853595
Name:LINDBLAD, RANDY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:E
Last Name:LINDBLAD
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0985
Mailing Address - Country:US
Mailing Address - Phone:360-748-1833
Mailing Address - Fax:360-748-3807
Practice Address - Street 1:68 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-0985
Practice Address - Country:US
Practice Address - Phone:360-748-1833
Practice Address - Fax:360-748-3807
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA58501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5006531Medicaid