Provider Demographics
NPI:1023213485
Name:DIAMOND, RANDOLPH MARK (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:MARK
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W END AVE
Mailing Address - Street 2:Y-1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2504
Mailing Address - Country:US
Mailing Address - Phone:212-873-2651
Mailing Address - Fax:
Practice Address - Street 1:285 W END AVE
Practice Address - Street 2:Y-1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2504
Practice Address - Country:US
Practice Address - Phone:212-873-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0340481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00418126Medicaid