Provider Demographics
NPI:1932119161
Name:RANDY L. SORENSEN DMD PA
Entity Type:Organization
Organization Name:RANDY L. SORENSEN DMD PA
Other - Org Name:FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-746-2668
Mailing Address - Street 1:939 BRYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5057
Mailing Address - Country:US
Mailing Address - Phone:208-746-2668
Mailing Address - Fax:
Practice Address - Street 1:939 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5057
Practice Address - Country:US
Practice Address - Phone:208-746-2668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty