Provider Demographics
NPI:1023188299
Name:RANDOLPH, GREGORY DWIGHT (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DWIGHT
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7300 BLANCO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4937
Mailing Address - Country:US
Mailing Address - Phone:210-344-9898
Mailing Address - Fax:210-344-9118
Practice Address - Street 1:7300 BLANCO RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4937
Practice Address - Country:US
Practice Address - Phone:210-344-9898
Practice Address - Fax:210-344-9118
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD123161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD12316OtherSTATE LICENSE NUMBER