Provider Demographics
NPI:1902032246
Name:RANDALL ORTHODONTICS, P.A.
Entity Type:Organization
Organization Name:RANDALL ORTHODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JARED
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-716-3690
Mailing Address - Street 1:3285 E. 17TH ST.
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3285 E. 17TH ST.
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6758
Practice Address - Country:US
Practice Address - Phone:208-716-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3405-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty