Provider Demographics
NPI:1780754820
Name:MAEBO, RANDALL M (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:M
Last Name:MAEBO
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 1:14030 NE 24TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3724
Mailing Address - Country:US
Mailing Address - Phone:425-644-8485
Mailing Address - Fax:425-644-8420
Practice Address - Street 1:14030 NE 24TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3724
Practice Address - Country:US
Practice Address - Phone:425-644-8485
Practice Address - Fax:425-644-8420
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist