Provider Demographics
NPI:1255534558
Name:RANDOLPH, CARLA MARTA (DDS)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:MARTA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9504
Mailing Address - Country:US
Mailing Address - Phone:517-614-4599
Mailing Address - Fax:
Practice Address - Street 1:7555 US12
Practice Address - Street 2:
Practice Address - City:ONSTED
Practice Address - State:MI
Practice Address - Zip Code:49265-9822
Practice Address - Country:US
Practice Address - Phone:517-467-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice