Healthcare Provider Details

I. General information

NPI: 1396148342
Provider Name (Legal Business Name): PAW PAW FAMILY DENTISTRY, PLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32800 E RED ARROW HWY
PAW PAW MI
49079-9401
US

IV. Provider business mailing address

32800 E RED ARROW HWY PO BOX 232
PAW PAW MI
49079-9401
US

V. Phone/Fax

Practice location:
  • Phone: 269-251-2286
  • Fax:
Mailing address:
  • Phone: 269-251-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019821
License Number StateMI

VIII. Authorized Official

Name: DR. BRADLEY CLAYTON RANDALL
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 269-657-4001