Provider Demographics
NPI:1770641797
Name:GRIFFIN, RANDY W (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:W
Last Name:GRIFFIN
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 1:2654 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3120
Mailing Address - Country:US
Mailing Address - Phone:727-787-4005
Mailing Address - Fax:727-786-8740
Practice Address - Street 1:2654 W LAKE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3120
Practice Address - Country:US
Practice Address - Phone:727-787-4005
Practice Address - Fax:727-786-8740
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL94401223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics