Provider Demographics
NPI:1295781417
Name:BRAITHWAITE, RANDY CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:CHARLES
Last Name:BRAITHWAITE
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 1:121 S 1370 E
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-2201
Mailing Address - Country:US
Mailing Address - Phone:801-785-9776
Mailing Address - Fax:
Practice Address - Street 1:121 S 1370 E
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-2201
Practice Address - Country:US
Practice Address - Phone:801-785-9776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5070492-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice