Healthcare Provider Details

I. General information

NPI: 1174624746
Provider Name (Legal Business Name): RANDALL WILLIAM BAETZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 DIXIE HWY
CLARKSTON MI
48346-2068
US

IV. Provider business mailing address

7150 DIXIE HWY
CLARKSTON MI
48346-2068
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-4455
  • Fax: 248-625-2942
Mailing address:
  • Phone: 248-625-4455
  • Fax: 248-625-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901011004
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: