Provider Demographics
NPI:1932267994
Name:RANDOLPH, BRYAN CLARK (DDS , MS)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:CLARK
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:DDS , MS
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Other - Credentials:
Mailing Address - Street 1:1954 DEL PASO RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-7706
Mailing Address - Country:US
Mailing Address - Phone:916-419-0020
Mailing Address - Fax:916-419-6787
Practice Address - Street 1:1954 DEL PASO RD
Practice Address - Street 2:SUITE #101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-7706
Practice Address - Country:US
Practice Address - Phone:916-419-0020
Practice Address - Fax:916-419-6787
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA417791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice