Provider Demographics
NPI:1790744332
Name:SMITH, RANDALL WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WAYNE
Last Name:SMITH
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 1:707 PIER VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-2801
Mailing Address - Country:US
Mailing Address - Phone:760-722-1451
Mailing Address - Fax:760-722-1476
Practice Address - Street 1:707 PIER VIEW WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2801
Practice Address - Country:US
Practice Address - Phone:760-722-1451
Practice Address - Fax:760-722-1476
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29855OtherLICENSE