Healthcare Provider Details

I. General information

NPI: 1801060702
Provider Name (Legal Business Name): RANDALL W. CHAMBERS, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6143 28TH ST SE
GRAND RAPIDS MI
49546-6941
US

IV. Provider business mailing address

6143 28TH ST SE
GRAND RAPIDS MI
49546-6941
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4650
  • Fax: 616-949-5377
Mailing address:
  • Phone: 616-949-4650
  • Fax: 616-949-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number17046
License Number StateMI

VIII. Authorized Official

Name: DR. RANDALL WAYNE CHAMBERS II
Title or Position: PRESIDENT
Credential: DDS
Phone: 616-949-4650