Provider Demographics
NPI:1740594779
Name:RANDOLPH, CARRIE MD (DDS)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MD
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 W MARINE WAY
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-7311
Mailing Address - Country:US
Mailing Address - Phone:907-486-3269
Mailing Address - Fax:
Practice Address - Street 1:506 W MARINE WAY
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-7311
Practice Address - Country:US
Practice Address - Phone:907-486-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1346OtherAK OCCUPATIONAL LICENSE