Provider Demographics
NPI:1669941852
Name:RANDON, DOMENIK (DMD)
Entity type:Individual
Prefix:DR
First Name:DOMENIK
Middle Name:
Last Name:RANDON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 MASTERS DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-2278
Mailing Address - Country:US
Mailing Address - Phone:910-578-9844
Mailing Address - Fax:
Practice Address - Street 1:5 WHITEVILLE TOWN CTR
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4401
Practice Address - Country:US
Practice Address - Phone:910-212-6613
Practice Address - Fax:910-267-8986
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist