Provider Demographics
NPI:1770668626
Name:EGGERT, RANDALL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:EGGERT
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 1:8575 164TH AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3679
Mailing Address - Country:US
Mailing Address - Phone:425-882-9116
Mailing Address - Fax:425-882-9136
Practice Address - Street 1:8575 164TH AVE NE
Practice Address - Street 2:SUITE 300
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3679
Practice Address - Country:US
Practice Address - Phone:425-882-9116
Practice Address - Fax:425-882-9136
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000075831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU64869Medicare UPIN