Provider Demographics
NPI:1750397410
Name:LONSBROUGH, RANDALL L (DDS)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:LONSBROUGH
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 1:628 CALIFORNIA BLVD
Mailing Address - Street 2:STE F1
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2574
Mailing Address - Country:US
Mailing Address - Phone:805-544-3204
Mailing Address - Fax:805-544-3240
Practice Address - Street 1:628 CALIFORNIA BLVD
Practice Address - Street 2:STE F1
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2574
Practice Address - Country:US
Practice Address - Phone:805-544-3204
Practice Address - Fax:805-544-3240
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406631223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40663Medicare UPIN