Provider Demographics
NPI:1790027217
Name:PETTY, RANDI MICHELLE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:RANDI
Middle Name:MICHELLE
Last Name:PETTY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 SE 82ND AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2958
Mailing Address - Country:US
Mailing Address - Phone:503-771-4324
Mailing Address - Fax:
Practice Address - Street 1:4104 SE 82ND AVE STE 450
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2958
Practice Address - Country:US
Practice Address - Phone:503-771-4324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5615124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist