Provider Demographics
NPI:1891480224
Name:RANDOLPH, KRISTIN (DMD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
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:GME ADMIN, 1200 EAST BROAD STREET
Mailing Address - Street 2:BOX 980257
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:VCUHS DEPT OF ORAL AND MAXILLOFACIAL SURGERY
Practice Address - Street 2:1250 EAST MARSHALL STREET
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0442000489390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program