Healthcare Provider Details

I. General information

NPI: 1235445883
Provider Name (Legal Business Name): RYAN ROBERT RANDOL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE CMR 402
APO AE
09180
US

IV. Provider business mailing address

LANDSTUHL DENTAL ACTIVITY CREDENTIALS OFFICE CMR 402
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 011496371929130
  • Fax: 011496371929117
Mailing address:
  • Phone: 011496371929130
  • Fax: 011496371929117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9481
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: