Provider Demographics
NPI:1952442774
Name:MOSENG, RANDALL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
Last Name:MOSENG
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 1:519 MCHUGH RD
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9256
Mailing Address - Country:US
Mailing Address - Phone:608-526-9300
Mailing Address - Fax:608-526-9310
Practice Address - Street 1:3143 STATE ROAD
Practice Address - Street 2:
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-788-0030
Practice Address - Fax:608-788-7881
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist