Healthcare Provider Details

I. General information

NPI: 1609188531
Provider Name (Legal Business Name): GRADY S RANDALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE
GRAND RAPIDS MI
49546-8371
US

IV. Provider business mailing address

1179 E PARIS AVE SE STE 130
GRAND RAPIDS MI
49546-3682
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-9840
  • Fax:
Mailing address:
  • Phone: 616-942-9840
  • Fax: 616-942-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN.00201849
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901022570
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: