Provider Demographics
NPI:1700950516
Name:WILLIAMS, RANDALL EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:EDWARD
Last Name:WILLIAMS
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 1:800 WALL ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2564
Mailing Address - Country:US
Mailing Address - Phone:219-531-0459
Mailing Address - Fax:219-464-9656
Practice Address - Street 1:800 WALL ST
Practice Address - Street 2:SUITE C
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2564
Practice Address - Country:US
Practice Address - Phone:219-531-0459
Practice Address - Fax:219-464-9656
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120097301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
799250OtherUNITED CONCORDIA INS