Provider Demographics
NPI:1831226117
Name:RANDALL L DAVIS DMD PC
Entity type:Organization
Organization Name:RANDALL L DAVIS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-686-8500
Mailing Address - Street 1:100 AMESBURY ST
Mailing Address - Street 2:STE 203
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-686-8500
Mailing Address - Fax:978-686-4032
Practice Address - Street 1:100 AMESBURY ST
Practice Address - Street 2:STE 203
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840
Practice Address - Country:US
Practice Address - Phone:978-686-8500
Practice Address - Fax:978-686-4032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11220OtherBC BS
MA9785914Medicaid
NH30312396OtherMEDICAI
MA046143185OtherDELTA DENTAL
MA30312696Medicare ID - Type Unspecified