Provider Demographics
NPI:1295094779
Name:RANDELL, MELISSA (DDS)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:RANDELL
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:PO BOX 8
Mailing Address - Street 2:PO BOX 578
Mailing Address - City:CANEY
Mailing Address - State:KS
Mailing Address - Zip Code:67333-0008
Mailing Address - Country:US
Mailing Address - Phone:620-879-2386
Mailing Address - Fax:620-879-5651
Practice Address - Street 1:301 S WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-4039
Practice Address - Country:US
Practice Address - Phone:918-336-1422
Practice Address - Fax:918-336-8633
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK63661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice