Provider Demographics
NPI:1790706653
Name:RANDOLPH C. PEARSON, D.D.S., P.S.
Entity Type:Organization
Organization Name:RANDOLPH C. PEARSON, D.D.S., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-2850
Mailing Address - Street 1:121 W POPLAR ST STE C
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2871
Mailing Address - Country:US
Mailing Address - Phone:509-525-2850
Mailing Address - Fax:509-529-6545
Practice Address - Street 1:121 W POPLAR ST STE C
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2871
Practice Address - Country:US
Practice Address - Phone:509-525-2850
Practice Address - Fax:509-529-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA49671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5512702Medicaid
WA5512702Medicaid