Provider Demographics
NPI:1942331426
Name:ROSE, RANDALL DAVIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVIS
Last Name:ROSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MAPLE ROW BLVD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3853
Mailing Address - Country:US
Mailing Address - Phone:615-822-4812
Mailing Address - Fax:615-822-4810
Practice Address - Street 1:111 MAPLE ROW BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3853
Practice Address - Country:US
Practice Address - Phone:615-822-4812
Practice Address - Fax:615-822-4810
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000031761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice