Provider Demographics
NPI:1801143110
Name:RANDLE DENTAL CLINIC
Entity type:Organization
Organization Name:RANDLE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-866-4741
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:RANDLE
Mailing Address - State:WA
Mailing Address - Zip Code:98377-0248
Mailing Address - Country:US
Mailing Address - Phone:360-497-5741
Mailing Address - Fax:360-497-5744
Practice Address - Street 1:214 SILVERBROOK RD
Practice Address - Street 2:
Practice Address - City:RANDLE
Practice Address - State:WA
Practice Address - Zip Code:98377
Practice Address - Country:US
Practice Address - Phone:360-497-5741
Practice Address - Fax:360-497-5744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60298156261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental