Healthcare Provider Details

I. General information

NPI: 1497843445
Provider Name (Legal Business Name): RANDALL J BLAZIC DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13980 W AVALON DR STE 120
GOODYEAR AZ
85395-1404
US

IV. Provider business mailing address

13980 W AVALON DR STE 120
GOODYEAR AZ
85395-1404
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-5774
  • Fax: 623-935-6524
Mailing address:
  • Phone: 623-935-5774
  • Fax: 623-935-6524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberM31657
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD5976
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: