Provider Demographics
NPI:1336437458
Name:DAVIS, RANDALL THOMASSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:THOMASSON
Last Name:DAVIS
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 1:3116 ACACIA DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5804
Mailing Address - Country:US
Mailing Address - Phone:307-634-3488
Mailing Address - Fax:
Practice Address - Street 1:3116 ACACIA DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5804
Practice Address - Country:US
Practice Address - Phone:307-634-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist