Provider Demographics
NPI:1982987608
Name:ROBERTS, RANDAL (DDS)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:ROBERTS
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 1:6321 S REDWOOD RD STE 206
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6321 S REDWOOD RD STE 206
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6972
Practice Address - Country:US
Practice Address - Phone:801-494-9839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5501438-99221223G0001X
UT5501438-89031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice