Provider Demographics
NPI:1013321678
Name:PRATHER, RANDON (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDON
Middle Name:
Last Name:PRATHER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-0585
Mailing Address - Country:US
Mailing Address - Phone:270-527-1479
Mailing Address - Fax:270-527-3192
Practice Address - Street 1:1301 OLIVE ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1640
Practice Address - Country:US
Practice Address - Phone:270-527-1479
Practice Address - Fax:270-527-3192
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY94921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice