MEDICARE: RANDALL L CALLISON D.D.S.

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	10382	TX

General Provider Information

NPI Number	:	1558453126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL L CALLISON D.D.S.

Provider Business Mailing Address
First Line	:	124 SANTA MONICA DR
Second Line	:
City	:	MABANK
State	:	TX
Zip	:	75156-4130
Country	:	US
Telephone Number	:	903-887-0383
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 S WASHINGTON ST
Second Line	:
City	:	KAUFMAN
State	:	TX
Zip	:	75142-3137
Country	:	US
Telephone Number	:	972-932-2311
Fax Number	:	972-932-4767

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	07/08/2007

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