Provider Demographics
NPI:1801937222
Name:RANDOLPH, GREGORY MARSHALL (D,DS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARSHALL
Last Name:RANDOLPH
Suffix:
Gender:
Credentials:D,DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3528
Mailing Address - Country:US
Mailing Address - Phone:309-663-1326
Mailing Address - Fax:309-662-3551
Practice Address - Street 1:119 N WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3528
Practice Address - Country:US
Practice Address - Phone:309-663-1326
Practice Address - Fax:309-662-3551
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0204161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370958381OtherTAX IDENTIFICATION NUMBER