MEDICARE: RANDY L BALL PLLC

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	1223E0200X	Endodontics	DE60539741	WA

General Provider Information

NPI Number	:	1679099246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDY L BALL PLLC

Provider Business Mailing Address
First Line	:	832 LANCASTER WAY SE
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98075-7176
Country	:	US
Telephone Number	:	425-281-7898
Fax Number	:

Provider Business Practice Location Address
First Line	:	336 228TH AVE NE STE 201
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98074-7290
Country	:	US
Telephone Number	:	425-657-0538
Fax Number	:	425-657-0772

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. RANDY L BALL
Credential	:	DMD, MSD
Telephone Number	:	425-281-7898

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	08/16/2017

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