Provider Demographics
NPI:1851422331
Name:RANDOLPH, RENITA WALDEN (DDS)
Entity Type:Individual
Prefix:
First Name:RENITA
Middle Name:WALDEN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13292 KENWICK CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-6446
Mailing Address - Country:US
Mailing Address - Phone:804-317-2227
Mailing Address - Fax:
Practice Address - Street 1:11551 NUCKOLS RD
Practice Address - Street 2:SUITE A
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5565
Practice Address - Country:US
Practice Address - Phone:804-273-6818
Practice Address - Fax:804-273-0347
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007596122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist