Provider Demographics
NPI:1871835868
Name:ROBERTSON, RANDAL C (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:C
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21202 OLEAN BLVD E2
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6723
Mailing Address - Country:US
Mailing Address - Phone:941-629-3200
Mailing Address - Fax:941-629-2113
Practice Address - Street 1:21202 OLEAN BLVD STE E2
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6723
Practice Address - Country:US
Practice Address - Phone:941-629-3200
Practice Address - Fax:941-629-2113
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 103791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice