Provider Demographics
NPI:1750540779
Name:RANDALL, BRADLEY CLAYTON (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:CLAYTON
Last Name:RANDALL
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:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0232
Mailing Address - Country:US
Mailing Address - Phone:269-657-4001
Mailing Address - Fax:
Practice Address - Street 1:104 MUNICIPAL LN
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1425
Practice Address - Country:US
Practice Address - Phone:269-657-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist