Provider Demographics
NPI:1821011388
Name:KNUDSON, RANDAL ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:ALAN
Last Name:KNUDSON
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 1:1893 SHERIDAN RD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2628
Mailing Address - Country:US
Mailing Address - Phone:847-432-0860
Mailing Address - Fax:847-432-2344
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:SUITE 315
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2628
Practice Address - Country:US
Practice Address - Phone:847-432-0860
Practice Address - Fax:847-432-2344
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice