MEDICARE: RANDALL C. BRETZING

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	1223G0001X	General Practice Dentistry	D2490	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0473020	OTHER		BLUE CROSS BLUE SHIELD
2	974453	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1528144052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL C. BRETZING

Provider Business Mailing Address
First Line	:	1727 N CHESTNUT CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-3416
Country	:	US
Telephone Number	:	480-329-5703
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 E UNIVERSITY DR
Second Line	:	SUITE 108
City	:	MESA
State	:	AZ
Zip	:	85213-8500
Country	:	US
Telephone Number	:	480-830-0262
Fax Number	:	480-981-8355

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RANDALL C. BRETZING
Credential	:	DDS
Telephone Number	:	480-329-5703

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	01/27/2015

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