Provider Demographics
NPI:1710035829
Name:RANDALL, CHARLES JARED (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JARED
Last Name:RANDALL
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 1:3285 E. 17TH ST.
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6758
Mailing Address - Country:US
Mailing Address - Phone:208-523-3380
Mailing Address - Fax:208-523-3077
Practice Address - Street 1:3285 E. 17TH ST.
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6758
Practice Address - Country:US
Practice Address - Phone:208-523-3380
Practice Address - Fax:208-523-3077
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3405-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806122100Medicaid