Provider Demographics
NPI:1932180601
Name:PERRY, RANDALL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:R
Last Name:PERRY
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 1:1430 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4240
Mailing Address - Country:US
Mailing Address - Phone:337-474-0212
Mailing Address - Fax:337-478-3837
Practice Address - Street 1:1430 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4240
Practice Address - Country:US
Practice Address - Phone:337-474-0212
Practice Address - Fax:337-478-3837
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA31881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice