Provider Demographics
NPI:1720181159
Name:RANDALL, MARK CALVERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CALVERT
Last Name:RANDALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 S 4TH AVE
Mailing Address - Street 2:STE 864
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2510
Mailing Address - Country:US
Mailing Address - Phone:502-387-8448
Mailing Address - Fax:502-387-8448
Practice Address - Street 1:455 S 4TH AVE
Practice Address - Street 2:STE 864
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2510
Practice Address - Country:US
Practice Address - Phone:502-387-8448
Practice Address - Fax:502-387-8448
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3470122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist