Provider Demographics
NPI:1770617615
Name:MALAN, RANDALL LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LYNN
Last Name:MALAN
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 1:1642 E HERNDON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3377
Mailing Address - Country:US
Mailing Address - Phone:559-261-2055
Mailing Address - Fax:
Practice Address - Street 1:1642 E HERNDON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3377
Practice Address - Country:US
Practice Address - Phone:559-261-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA362601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics