Healthcare Provider Details

I. General information

NPI: 1891788345
Provider Name (Legal Business Name): RANDALL TED TAYLOR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 OAK ST
RED BLUFF CA
96080-3304
US

IV. Provider business mailing address

343 OAK ST
RED BLUFF CA
96080-3304
US

V. Phone/Fax

Practice location:
  • Phone: 530-529-2567
  • Fax: 530-529-2552
Mailing address:
  • Phone: 530-529-2567
  • Fax: 530-529-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: