MEDICARE: BRIAN RANDLE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4332	NV
2	122300000X	Dentist	54973	CA
3	122300000X	Dentist	9734638889221	UT

General Provider Information

NPI Number	:	1518053412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN RANDLE DMD

Provider Business Mailing Address
First Line	:	2263 S 2200 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1134
Country	:	US
Telephone Number	:	801-541-9504
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 BRICKYARD RD
Second Line	:	32B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2565
Country	:	US
Telephone Number	:	801-474-9552
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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