Provider Demographics
NPI:1962829366
Name:COLLEGE AVENUE DENTAL SLEEP APPLIANCES LTD.
Entity Type:Organization
Organization Name:COLLEGE AVENUE DENTAL SLEEP APPLIANCES LTD.
Other - Org Name:RANDALL E LAWSON DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:EVERT
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-473-6758
Mailing Address - Street 1:505 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2405
Mailing Address - Country:US
Mailing Address - Phone:217-245-5313
Mailing Address - Fax:217-383-0204
Practice Address - Street 1:505 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2405
Practice Address - Country:US
Practice Address - Phone:217-245-5313
Practice Address - Fax:217-383-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019857332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies