Provider Demographics
NPI:1730306275
Name:BROOM, RANDALL DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DOUGLAS
Last Name:BROOM
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 1:4710 UNIVERSITY WAY NE
Mailing Address - Street 2:#201
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4427
Mailing Address - Country:US
Mailing Address - Phone:206-525-1414
Mailing Address - Fax:
Practice Address - Street 1:4710 UNIVERSITY WAY NE
Practice Address - Street 2:#201
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4427
Practice Address - Country:US
Practice Address - Phone:206-525-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist