Provider Demographics
NPI:1245442573
Name:BLAKEMAN, RANDOLPH F (DDS)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:F
Last Name:BLAKEMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 SARATOGA RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4515
Mailing Address - Country:US
Mailing Address - Phone:518-399-9450
Mailing Address - Fax:518-399-9465
Practice Address - Street 1:184 SARATOGA RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4515
Practice Address - Country:US
Practice Address - Phone:518-399-9450
Practice Address - Fax:518-399-9465
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041658-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01193911Medicaid