Provider Demographics
NPI:1972067072
Name:RANDOLPH DENTAL GROUP LLC
Entity Type:Organization
Organization Name:RANDOLPH DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-562-0469
Mailing Address - Street 1:500 CHAPMAN ST UNIT 201
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 FRANK LEARY WAY UNIT 4
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4503
Practice Address - Country:US
Practice Address - Phone:781-963-7204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDOLPH DENTAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty